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THE 


PATHOLOGY, 
DIAGNOSIS  AND   TREATMENT 


DISEASES 


EECTUM  and  anus 


CHARLES   B.   KELSEY,   M.D. 

SURGEON   TO   ST.    PAUL'S   INFIRMARY  FOR  DISEASES    OF    THE   RECTUM  ;     CONSULTING 

SURGEON   FOR  DISEASES   OF  THE   RECTUM  TO   THE   HARLEM   HOSPITAL  AND 

DISPENSARY  FOR  WOMEN  AND  CHILDREN,    ETC. 


With  Two  Chromo-lithographs  and  Nearly  One  Hundred  Illustrations 


NEW  YORK 
WILLIAM    WOOD     &    COMPANY 

56  &  58  Lafayette  Place 
1884 


Copyright 

WILLIAM    WOOD  &  COMPANY 

1S84 


1  ROW'S 

PRINTING  AND  BOOK6IN0ING  COMPANY. 

NtW   YORK. 


PREFACE. 


This  work,  while  having  for  its  basis  the  volume  on  the  same  sub- 
ject contributed  by  me  to  "Wood's  Library  of  Standard  Medical  Au- 
thors "  in  1883,  contains  many  changes,  chiefly  of  such  practical  char- 
acter as  would  naturally  be  suggested  to  a  writer  by  the  increased 
experience  which  comes  from  the  daily  practice  of  a  specialty. 

The  chapter  on  Rectal  Hernia  has  been  added  entire,  and  many 
new  illustrations  have  been  introduced. 

While  an  effort  has  been  made  to  bring  each  branch  of  the  subject 
fully  up  to  date,  and  what  seemed  sufficient  space  has  been  accorded 
to  questions  of  pathology,  and  the  literature  on  all  points  has  been 
fully  indicated,  so  that  the  reader  may  easily  follow  out  any  doubtful 
question  for  himself — my  special  aim  has  been  to  make  the  book  a 
safe  guide  for  the  student  and  general  practitioner,  and  to  furnish,  as 
far  as  possible  in  this  way,  that  information  which  it  is  so  difficult  to 
acquire  without  the  time  and  opportunity  for  special  clinical  study. 


Charles  B.  Kelsey. 


Tite  Madison,  25  Madison  Avenue, 
New  York,  1884. 


CONTENTS. 


CHAPTEE  I. 

PRACTICAL    POINTS    IN    ANATOMY    AND    PHYSIOLOGY. 

PAGE 

Rectum. — Position  and  Measurements. — Curves. — Divisions. — Eelations. — Anus. 
— Parts  in  Detail. — Peritoneum. — Relations  to  Three  Portions  of  the  Rec- 
tum.— Distance  of  Peritoneal  Cul-de  b'ac  from  Anus. — Muscular  Layer. — Ar- 
rangement of  Fibres. — Submucous  Layer. — Mucous  Membrane.— Sustentator 
Tunicas  Mucosas. — Columnar  Recti. — Glands  of  Mucous  Membrane. — Muscles 
of  the  Rectum  and  Anus. — External  Sphincter. — Internal  Sphincter.— Recto- 
Coccygeus. — Levator  Ani. — Transver&us  Perinei. — Arteries. — Superior  Haem- 
onhoidal.  — Middle  Hemorrhoidal.  — Inferior  Ha3m0rrh0id.nl.  — Veins. — Su- 
perior Hasmorrhoidal. —  Middle  Hasmorrhoidal. — Inferior  Haamorrhoidal. — 
Minute  Anatomy  of  Veins. — General  and  Visceral  Venous  Systems  — Nerves. 
— Cerebro-Spinal  and  Sympathetic  Nerve-Supply.  —  Tonic  Contraction  of 
Sphincter.  —  Explanation  of  Wandering  Pains  in  Rectal  Disease.  —  Lym- 
phatics.— External  and  Internal  Lymphatic  Vessels. — Physiology. — Anatomy 
of  the  Third  Sphincter. — Valves  of  Mucous  Membrane. — Plica  Transversalis 
Recti  of  Kohlrausch. — Lack  of  Uniformity  in  Different  Subjects. — Physiology 
of  Defecation. — Explanation  of  Retention  of  Fasces  after  Destruction  of  the 
Sphincter. — Conclusions  Resulting  from  Study  of  Third  Sphincter 1 

CHAPTEE  H. 

CONGENITAL   MALFORMATIONS   OF   THE   RECTUM   AND   ANUS. 

Separate  Development  of  Rectum  and  Anus. — Narrowing  of  the  Anus  or  Rectum 
without  Complete  Occlusion. — Congenital  Stricture. — Closure  of  the  Anus  by 
a  Membranous  Diaphragm. — Entire  Absence  of  the  Anus,  the  Rectum  ending 
in  a  Blind  Pouch  at  a  Point  more  or  less  Distant  from  the  Perineum. — Rec- 
tum Same  as  in  Last  Variety  and  the  Anus  Normal. — Anus  Absent  and  Rec- 
tum Opening  by  an  Abnormal  Anus  at  Some  Point  in  the  Perineal  or  Sacral 
Regions. — Cases. — Anus  Absent  and  Rectum  Ending  in  the  Bladder,  Urethra, 
or  Vagina. — Cases. — Rectum  and  Anus  Normal,  but  Ureters,  Uterus,  or  Vagina 
Empty  into  Rectum. — Total  Absence  of  Rectum. — Absence  of  Large  Intes- 
tine.—  Obliteration  from  Intra-uterine  Disease.  —  Treatment  — Operation 
should  always  be  Performed  and  without  Delay. — Attempt  should  first  be  made 


VI  CONTENTS. 

PAGE 

to  Establish  an  Anus  in  the  Anal  Region. — Measurements  of  Pelvis  at  Birth. — 
Use  of  Trocar  not  Justifiable.  —  Useful  Anus  Seldom  Obtained  by  Means  of  In- 
cision AloDe. — Objections  to  Cutting  Operation  without  Plastic  Operation. — 
Proctoplasty. — If  Attempt  to  Establish  New  Anus  in  Anal  Region  Fail,  Colo- 
tomy  at  once  to  be  Performed. — Inguinal  Preferable  to  Lumbar  Colotomy. — 
History  of  Colotomy. — Callisen. — Amussat. — Description  of  Operation  of 
Colotomy. — Dangers  of  Operation. — The  Inguinal  Operation. — Description. — 
Attempts  at  Establishing  Anus  in  Anal  Region  after  Colotomy  Generally 
Unsuccessful. — Cases. — Closure  of  Artificial  Anus. —Operation  of  Dupuytren. 
— Modifications  of  Dupuytren's  Operation. — Byrd's  Operation 86 


CHAPTEE  in. 

GENERAL   RULES    REGARDING    EXAMINATION,    DIAGNOSIS,    AND    OPERATION. 

Necessity  for  Physical  Examination. — Questions  which  may  Lead  to  Diagnosis. — 
How  to  make  Examination. — Table. — Lamp. — Instrument  Case. — Position  of 
Patient. — Necessity  for  Enema  before  Examination. — Apparatus  for  In- 
jections.— What  may  be  Learned  by  Simple  Inspection. — Rectal  Touch. — 
What  may  be  Discovered  by  it. — Bougies:  Varieties;  Author's  Bougies. — 
Rectal  Specula  :  Helmuth's  ;  Author's ;  Fenestrated  ;  Bivalve ;  Objections. 
— Colonoscope. — Stretching  the  Sphincter;  Proper  Method  of  Performing 
the  Operation  ;  Results. — Difficulties  of  Diagnosis  of  Disease  high  up  in  the 
Rectum. — Manual  Examination. — What  may  be  Learned  by  this  Method. — 
Preparation  of  Patient  for  Operation. — Assistants.  — Primary  Anaesthesia. — 
Thermo-Cautery. — Haemorrhage. — Rules  for  Controlling  Haemorrhage. — Cold. 
— Styptics. — Packing  the  Rectum. — Treatment  after  Operation. — Dressings. 
— Necessity  for  Rest. — Retention  of  Urine. — Case  of  Fatal  Retention 59 

CHAPTER  IV. 

INFLAMMATION   OF   THE   RECTUM. 

Cases  of  Proctitis. — Varieties  :  Acute,  Chronic,  Primary,  Secondary,  Localized, 
General.— Symptoms  and  Course  of  each  Variety. — Causes  of  Proctitis  :  Direct 
Propagation,  Foreign  Bodies,  Drastic  Cathartics,  Gout,  Pederasty,  Gonor- 
rhoea.— Treatment 84 

CHAPTER  V. 

ABSCESS    AND    FISTULA. 

\bscess,  divided  into  Superficial  and  Deep.— Superficial  Abscesses.— Simple  Fu- 
runcles: Causes;  Characters;  Results;  Treatment.  — Suppuration  of  External 
Haemorrhoid. — Suppuration  of  Internal  Hemorrhoid.—  Diffuse  Inflammation 
of  Subcutaneous  Tissue  :  Causes  ;  Symptoms  ;  Treatment. — Form  of  Incision. 
—  Deep  Abscesses. — Divided  into  Abscess  of  the  Ischio- Rectal  Fossa  and  of 


CONTENTS.  Vll 


the  Superior  Pelvi-Rectal  Space. — Description  of  Superior  Pelvi-Rectal  Space. 
— Causes  of  Deep  Abscess. — Residual  Abscess. — Symptoms  arid  Cases  of  Deep 
Abscess. — Dangers  of  Deep  Abscess. — Formation  of  Deep  and  Extensive  Fis- 
tulas.— Horse-shoe  Abscess. — Idiopathic  Gangrenous  Cellulitis. — Reasons  why 
Abscesses  do  not  Heal  Spontaneously. — Diagnosis. — Prognosis. — Treatment. 
— Incisions  and  Subsequent  Treatment  of  Deep  Abscess. — Danger  of  Incon- 
tinence.— Relief  of  Incontinence  by  Operation. — Fistula.  — Generally  due  to 
Abscess. — Divided  into  Superficial  and  Deep. — Complete  Fistula. — External 
Fistula, — Internal  Fistula. — Description  of  Superficial  Fistula?. — How  to  De- 
tect an  Internal  Opening. — Location  of  Internal  Opening. — Description  of 
Track  of  Fistula. — Symptoms  of  Superficial  Fistula. — Deep  Fistula.  —  Fistula 
with  Numerous  External  Openings. — Pelvic  Fistula. — Blind  Internal  Fistula. 
— Ulceration  of  Rectum  Causing  Internal  Fistula. — Treatment. — Spontane- 
ous Cure. — Advisability  of  Operation. — Fistula  in  Relation  to  Phthisis. — 
Contra-indications  to  Operation. — Treatment  by  Cauterization. — The  Liga- 
ture.— The  Elastic  Ligature. — Galvano-Cautery. — How  to  Pass  Ligature. — 
Incision. — Description  of  Operation. — Author's  Knife  for  Fistula, — Division 
of  Deep  Tracks. — Treatment  of  Track  running  up  the  Bowel. — Treatment  of 
Blind  External  Variety  ;  of  Horse-shoe  Variety  ;  of  Fistula  with  Numerous 
External  Openings. — Dressing  after  Incision. — Packing  the  Incision. — Haem- 
orrhage in  Operation. — Treatment  of  Blind  Internal  Variety. — Incurable  Fis- 
tula?. — Treatment  of  Deep  and  Extensive  Tracks.  — Fistula  with  Stricture ...     90 

CHAPTEE  YX 

HEMORRHOIDS. 

Definition. — Division  into  External,  Internal,  and  Intermediate. — Differences  be- 
tween the  two  Varieties. — External  Haemorrhoids. — Pathology. — Inflamed 
Haemorrhoids. — Treatment. — Means  of  Prevention. — Palliative  Treatment. — 
Excision. — Internal  Haemorrhoids.- — Division  into  Capillary,  Arterial,  and 
Venous. — Description  of  Capillary  Variety,  of  Venous  Variety,  of  Arterial 
Variety. — Symptoms  of  Internal  Haemorrhoids. — Strangulation. — Diagnosis. 
— Treatment  of  Internal  Haemorrhoids.- — Palliative  Treatment. — Constitu- 
tional and  Local  Means' of  Palliation. — Treatment  of  Strangulation. — Cura- 
tive Treatment. — Haemorrhoids  Associated  with  Uterine  Disease.  —  Sympto 
matic  Haemorrhoids. — Radical  Cure. — Caustics. — Dangers  of  Nitric  Acid. — 
Vienna  Paste. — Treatment  by  Carbolic  Acid  Injections;  Cases  and  Cures. — 
Advantages  of  this  Treatment. — Treatment  by  Ligature. — Description  of 
Operation. — Operation  with  Clamp  and  Cautery 126 

CHAPTEE   VTI. 

PROLAPSE. 

Four  Varieties. — First  Variety:  Prolapse  of  the  Mucous  Membrane  Alone. — 
Second  Variety:  Prolapse  of  all  the  Coats  of  the  Rectum. — Third  Variety: 
Prolapse  of  the  Upper  Part  of  the  Rectum  into  the  Lower,  or  Invagination. — 
Fourth  Variety  :  Invagination  in  the  Continuity  of  the  Bowel. — Prolapse  of 


VI 11  CONTENTS. 

PAGE 

the  Mucous  Membrane  Alone. — Causes. — Symptoms. — Treatment :  Palliative 
and  Curative. — Prolapse  with  Haemorrhoids. — Treatment  by  Injections. — 
Cauterization. — Description  of  Operation. — -Smith's  Clamp. — Dupuytren's 
Operation. — Prolapse  of  tbe  Second  Degree. — Pathological  Changes. — Pres- 
ence of  Peritoneum. — Strangulation. — Advisability  of  Reducing  Inflamed  or 
Gangrenous  Prolapse. — Excision  of  Prolapse  after  the  Formation  of  a  Slough. 
— Third  and  Fourth  Varieties. — Differences  between  Third  and  Fourth. — De- 
grees of  Invagination. — Anatomical  Appearances. — Pathology. — Relative  Fre- 
quency.— Symptoms. — Physical  Signs. — Acute  and  Chronic  Forms. — Diag- 
nosis.— Differential  Diagnosis  from  Volvulus ;  from  Stricture  ;  from  Internal 
Hernia  ;  from  Obstruction  by  Pressure  from  without  the  Bowel  ;  from  For- 
eign Bodies  ;  from  Peritonitis  with  Perforation. — Treatment. — Replacement 
by  Manipulation  ;  by  Injections. — Treatment  by  Puncture. — Laparotomy. — 
Description  of  Operation. l.~6 


CHAPTER  YHL 

RECTAL   HERNIA. 

Definition. — Generally  a  Complication  of  Prolapsus. — Cases. — Anatomy. — The 
Pelvic  Diaphragm. — Relation  of  Pelvic  Diaphragm  to  Rectal  Hernia. — Varie- 
ties of  R,ectal  Hernia. — Internal  and  External  Hernia.— Hernia  without  a 
Sac. — Rupture  of  the  Rectum  usually  a  Result  of  Hernia. — Changes  in  the  Sac 
which  lead  to  Rupture. — Location  and  Extent  of  Rupture. — Cause  of  Rup- 
ture.— Contents  of  Hernial  Sac. — Hernia  may  be  Reducible.  Irreducible,  In- 
flamed, or  Strangulated. — -Causes  of  Irreducibility. — Symptoms  of  Inflamed 
Hernia. — Seat  of  Constriction  in  Strangulation. — Diagnosis. — Treatment. — 
Method  of  Reduction. — Operations  for  Radical  Cure. — Kleberg's  Operation 
with  Elastic  Ligature.  —  Treatment  of  Inflamed  Hernia.  —  Treatment  of 
Strangulation. — Incision  into  Sac. — Laparotomy. — Treatment  after  Rupture. 
— Reduction  of  Inflamed  Intestine 182 


CHAPTER  TX. 

NON-MALIGNANT   GROWTHS   OF   THE   RECTOl    AND   AKDS. 

Polypus. — Definition. — Hypertrophy  of  Villi. — Characteristics. — Villous  Tumor. 
— Adenomatous  Polypus. — Fibrous  Polypus. — Structure;  Characteristics. — 
Symptoms  of  Polypus. — Diagnosis. — Diagnosis  from  Malignant  Disease. — 
Treatment.  —  Vegetations.— Definition. —  Description.— Microscopic  Appear- 
ances.— Relation  to  Syphilis.  — Symptoms  of  Vegetations. — Diagnosis. — Treat- 
ment— Condylomata. — Distinction  between  Condylomata  and  Vegetations. 
—Description. — Syphilitic  and  Xon  syphilitic  Condylomata. —Benign  Fun- 
gus— Gummata. — Rarity  and  Literature. — Ano-rectil  Syphiloma. — Definition 
ol  Fournier. — Fibromata. —  Lipomata — Characteristics. — Enchondromata. — 
—  Dermoid  Growths.  —  Characters.  —  Pilonidal  Sinns.  —  Hydatids. — 
Fcetal  Inclusions. — Spina  Bifida. — Congenital  Cysts 213 


CONTENTS.  IX 


CHAPTEK  X. 

XOX-ilAIiaSAXT   ULCERATION. 

PAGE 

Varieties. — Simple  Ulcers. — Generally  due  to  Traumatism. — Various  Forms  of  In- 
jury to  which  Rectum  is  Subject. — Sodomy. —Injury  of  Rectum  in  Labor. 
— Ulcers  due  to  Surgical  Interference. —Fissure  or  Irritable  Ulcer. — Nothing 
Distinctive  in  the  Ulcerative  Process. — Characteristics  of  Irritable  Ulcer. — 
Theories  concerning  this  Form  of  Ulcer. — Description. — Herpes. — Tubercular 
Ulceration. — Distinction  between  True  Tubercular  Ulcer  and  a  Simple  Ulcer 
in  a  Tuberculous  Person. — Description  of  Each. — Scrofulous  Ulceration. — 
Esthiomene. — Rodent  Ulcer. — Dysentery. — A  Cause  of  Stricture. — Venereal 
Ulceration. — Gonorrhoea. — Chancroids.  ■ — Chancroidal  Stricture. — Discussion. 

—  True  Chancre. — Secondary  and  Tertiary  Syphilitic  Ulcerations. — Diag- 
nosis of  Syphilitic  Ulcers.  — Ano-rectal  Syphiloma  as  a  Cause  of  Ulceration. 
— Ulceration  Secondaiy  to  Stricture. — Gangrene. — Symptoms  of  Ulceration. 

—  Gravity  of  the  Disease. — Diagnosis. — Treatment.  —  General  and  Local 
Measures. —  Treatment  of  Fissure. —  Fissure  Complicated  with  Polypus. — 
Treatment  by  Rest.  Fluid  Diet,  and  Incision  of  the  Sphincter. — Local 
Applications 241 


CHAPTEE  XI. 

NON-MAIIGNANT    STRICTURE   OF   THE   RECTUM. 

Strictures  Divided  into  Congenital  and  Acquired. — Table  of  Subdivisions. — Com- 
plete and  Partial  Congenital  Stricture. — Acquired  Stricture. — Stricture  due 
to  Pressure  from  Without. — Spasmodic  Stricture. — Non-venereal  Strictures. 
—  Dysenteric  Stricture. — Stricture  due  to  Enlargement  of  Valves  of  the  Rec- 
tum.— Traumatic  Stricture. — Venereal  Stricture. — Divided  into  Cicatricial 
and  Neoplastic.  —  Cicatricial  Venereal  Stricture. — Neoplastic  Venereal  Strict- 
ure.— Pathological  Anatomy. — Changes  in  Rectal  Wall  above  and  below  the 
Stricture. — Changes  in  Parts  around  the  Stricture. — Symptoms. — Value  of 
Flattened  Passages  as  Symptom. — Signs  of  Obstruction. — Obstruction  with 
Stricture  of  Considerable  Calibre. — Diagnosis. — Dangers  to  be  Avoided  in  Ex- 
amination.— Difficulty  when  Disease  is  Situated  high  up  in  the  Bowel. — Use 
of  Bougie  for  Diagnosis. — Treatment. — Advisability  of  Anti-syphilitic  Medi- 
cation.—  Palliative  Treatment.  —  Medicinal  Treatment  of  Threatened  Ob- 
struction.— Surgical  Measures. — Dilatation,  Gradual  or  Sudden. — Rules  for 
Gradual  Dilatation. — Divulsion,  Dangers  of.  and  Methods  of  Performing. — 
Treatment  by  Free  Division. — Description  of  Operation. — Collection  of  Cases. 
— Results  of  this  Treatment. — Comparison  with  Colotomy. — Cases  from  Au- 
thor's Practice. — Knife  for  Operation. — Excision  of  Non-malignant  Stricture. 
— Colotomy. — Restrictions  to  the  Operation. — General  Considerations  Regard- 
ing it. — Treatment  of  Stricture  High  Up 271 


CONTENTS. 


CHAPTER  XII. 


PAGE 

General  Characters  of  Malignant  as  Distinguished  from  Benign  Growths. — Malig- 
nant, Semi-malignant,  and  Benign  Adenoma. — Encephaloid. — Colloid. — Mel- 
anotic Cancer. — Osteoid  Cancer. — Age  at  which  Cancer  occurs. — Symptoms. 
— Diagnosis. — Treatment. — Excision:  History  and  Besults  of  Operation. — 
Conclusions  Regarding  Excision. — Modes  of  Performing  the  Operation. — 
Excision  of  Cancer  of  the  Sigmoid  Flexure. — Palliative  Treatment 320 


CHAPTER  XHL 

IMPACTED    F^CES    AND    FOREIGN   BODIES. 

Impacted  Faeces. — Intestinal  Concretions. — Diagnosis  and  Treatment  of  Impac- 
tion.— Foreign  Bodies  Swallowed. — Results  which  may  Follow  the  Swallow- 
ing of  a  Foreign  Body. — Ulceration  and  Abscess. — Foreign  Bodies  Introduced 
per  Anum. — Cases. — Prognosis. — Treatment. — Dangers  of  Attempts  at  Remo- 
val.— Laparotomy  for  Removal. — Cases  Successful 364 

CHAPTER  XIV. 

PRURITUS    ANL 

Pruritus  generally  a  Symptom  of  some  other  Disease. — Description. — Causes. — 
Relation  of  Internal  Haemorrhoids,  Fistula,  Worms,  Parasites,  and  Eczema 
to  Pruritus. — Treatment  of  Eczema. — Herpes  and  Erythema. — Constitutional 
Conditions  causing  Pruritus. — Dependence  upon  Constipation. — Treatment 
of  Constipation. — General  Treatment  of  Pruritus 385 

CHAPTER  XV. 

SPASM   OF   THE   SPHINCTER. — NEURALGIA. — WOUNDS. — HEMORRHAGE. — RECTAL 

ALIMENTATION. 

Spasm  without  other  Disease.— Cases. — Authorities. — Symptoms.— Treatment  — 
Neuralgia. —  Cases. —  Diagnosis. —  Treatment. —  Wounds. —  Complications. — 
Spontaneous  Rupture.— Treatment  of  Wounds.— Haemorrhage  from  the  Rec- 
tum.— Necvub  of  the  Rectum.— Alimentation.— Physiology  of  Absorption. 
—Nutritive  Enemata.  —Nutritive  Suppositories 395 


LIST  OF  ILLUSTRATIONS. 


PLATE  I.— Chancroids  of  Anus  and  Vulva.     (Pean  and  Malassez.) 
PLATE  II.— Hemorrhoids  and  Prolapsb.     (Esmarch.) 
Fig.  1.  Intermediate  Hemorrhoids. 

"     2.  Prolapse. 

"     3.  Internal  Hemorrhoids  with  Prolapse. 

"     4.  Inflamed  External  Hemorrhoids. 

FIG.  PAGE 

1.  Antero-Posterior  Curve  of  the  Rectum 2 

2.  Section  of  Normal  Rectal  Wall 9 

3.  Section  of  Rectal  Mucous  Membrane 10 

4.  Rectal  Veins  Seen  from  Without 17 

5.  Rectal  Veins  Seen  from  Within 18 

6.  Nerves  of  the  Anus 22 

7.  Rectum  Ending  in  a  Blind  Pouch 38 

8.  Rectum  Ending  in  a  Blind  Pouch  with  Normal  Anus 39 

9.  Rectum  Ending  in  the  Clans  Penis 40 

10.  Rectum  Ending  in  the  Bladder 42 

11.  Needles  for  Passing  Sutures  in  Colotomy 51 

12.  Condition  of  the  Bowel  after  Colotomy 56 

13.  Idem 56 

14.  Enterotome  of  Dupuytren  .  „ 56 

15.  Gynecological  Chair  Closed 62 

16.  Gynecological  Chair  Opened 62 

17.  Lamp  for  Rectal  Examination 63 

18.  Sponge  Holder 64 

19.  Brush  on  Flexible  Handle 64 

20.  Cup  for  Fusing  Nitrate  of  Silver 64 

21.  Applicator 64 

22.  Instrument  Case 65 

23.  Apparatus  for  Injections 66 


Xll  LIST    OF    ILLUSTRATIONS. 

FIG.  PAGE 

24.  Pes  Basin 67 

25.  Soft  Rubber  Bougie  with  Blunt  Point 70 

26.  Soft  Rubber  Bougie  with  Sharp  Point 70 

27.  Bougie  a  Boule 71 

28.  Soft  Bougie  of  Red  Rubber 71 

29.  Helmuth's  Speculum  . . .' 74 

30.  Author's  Speculum 74 

31.  Fenestrated  Cylindrical  Speculum 75 

32.  Bivalve  Speculum 75 

33.  Rectal  Depressor 76 

34.  Coloxoscope : 76 

35.  Paquelln's  Thermo-Cautery .     80 

36.  Operation  for  Faecal  Incontinence 106 

37.  Varieties  of  Fistula 107 

38.  Fistula  with  Double  Tracks 109 

39.  Idem , 109 

40.  Allingham's  Ligature  Holder 117 

41.  Helmuth's  Ligature  Holder 117 

42.  Fistula  Knife , 119 

43.  Gorget 119 

44.  Operation  with  Gorget 120 

45.  Spring  Scissors  for  Fistula 120 

46.  Enterotome  of  Riciiet 124 

47.  External  Venous  Hemorrhoid 128 

48.  External  Cutaneous  Hemorrhoid 129 

49.  Knife  for  Incising  Hemorrhoids 129 

50.  External  Hemorrhoid  with  Increase  of  Connective  Tissue 131 

51.  External  Hemorrhoid  after  Injection  of  Vein 131 

52.  Internal  Hemorrhoids,  showing  Junction  of  Skin  and  Mucous  Mem- 

brane   134 

53.  Syringe  for  Injecting  Hemorrhoids 148 

54.  Hemorrhoidal  Forceps 149 

55.  Idem 151 

56.  Luer's  Forceps 151 

57.  Smith's  Clamp  and  Cautery  Irons 154 

58.  First  Variety  of  Prolapse 157 

59.  Second  Variety  of  Prolapse 157 

60.  Thikd  Variety  of  Prolapse 158 

61.  Rectal  Supporter 161 

62.  Sharp-Pointed  Cautery  Iron 165 

63.  Prolapse  Composed  of  all  this  Coats  of  the  Rectum 166 


LIST    OF    ILLUSTRATIONS.  Xlll 

FIG.  PAGE 

64.  Pbolapse  of  Invaginated  Intestine 170 

65.  Pelvic  Diaphragm 199 

66.  Idem,  showing  Formation  of  Hernia 200 

67.  Sac  of  Rectal  Hernia 201 

68.  Internal  Rectal  Hernia 202 

69.  Rectal  Polypus 214 

70.  Villous  Polypus 215 

71.  Glandular  Polypus 216 

72.  Vertical  Section  of  Polypus 218 

73.  Vegetations 222 

74.  Condyloma 228 

75.  Congenital  Tumor  of  Ano-Rectal  Region 237 

76.  Tubercular  Ulcer 248 

77.  Syphilitic  Ulceration  of  Colon 258 

78.  Section  of  Stricture 274 

79.  Stricture  showing  Hypertrophy 277 

80.  Rectal  Dilator  .* 295 

81.  Wales'  Dilator 296 

82.  Proctotomy  Knife 301 

83.  Section  of  Cancer  of  the  Rectum 321 

84.  Cancerous  Stricture 337 

85.  Wire  Ecraseur 362 

86.  Simon's  Scoop 362 

87.  Dull  Scoop  for  Removing  Faeces 369 

88.  Pruritus  Ani  386 


DISEASES 


OF  THE 


EECTUM   AND   ANUS. 


CHAPTER  I. 

PRACTICAL  POINTS   IN  ANATOMY  AND  PHYSIOLOGY. 

Rectum.  — Position  and  Measurements. — Curves.  — Divisions.  — Relations.  — Anus.  — 
Parts  in  Detail. — Peritoneum. — Relations  to  Three  Portions  of  the  Rectum. — 
Distance  of  Peritoneal  Oul-de-Sac  from  Anus. — Muscular  Layer. — Arrangement 
of  Fibres. — Submucous  Layer. — Mucous  Membrane. — Sustentator  Tunice  Muco- 
sae.— Columne  Recti. — Glands  of  Mucous  Membrane.— Muscles  of  the  Rectum 
and  Anus. — External  Sphincter. — Internal  Sphincter. — Recto-Coccygeua. — Leva- 
tor Ani.  —  Transversus  Perinei.  —  Arteries.  —  Superior  Hemorrhoidal.  —  Middle 
Hemorrhoidal.  — Inferior  Hemorrhoidal.  — Veins. — Superior  Hemorrhoidal. — 
Middle  Hemorrhoidal. — Inferior  Hemorrhoidal. — Minute  Anatomy  of  Veins. — 
General  and  Visceral  Venous  Systems. — Nerves. — Cerebro- Spinal  and  Sympa- 
thetic Nerve-Supply. — Tonic  Contraction  of  Sphincter. — Explanation  of  Wander- 
ing Pains  in  Rectal  Disease. — Lymphatics. — External  and  Internal  Lymphatic 
Vessels. — Physiology. — Anatomy  of  the  Third  Sphincter. — Valves  of  Mucous  Mem- 
brane.— Plica  Transversalis  Recti  of  Kohlrausch. — Lack  of  Uniformity  in  Differ- 
ent Subjects. — Physiology  of  Defecation. — Explanation  of  Retention  of  Feces 
after  Destruction  of  the  Sphincter.  — Conclusions  Resulting  from  Study  of  Third 
Sphincter. 

The  rectum  is  the  terminal  portion  of  the  large  intestine  extend- 
ing from  the  sigmoid  flexure  to  the  anus.  In  its  natural  posi- 
tion its  length  varies  in  different  persons  from  six  to  eight 
inches.  When  dissected  out  of  the  body  and  straightened,  it 
will  be  found  to  measure  about  two  inches  more.  Its  position 
in  the  true  pelvis  is  comparatively  fixed,  and  its  fixity  renders 
it  the  more  liable  to  those  displacements,  such  as  invagination 
and  prolapse,  which  are  due  to  straining  at  stool,  and  accounts 
also  for  the  fact  that,  when  denuded  by  the  destruction  of  the 


2  DISEASES    OF    THE    KECTUM    AND    ANUS. 

surrounding  cellular  tissue,  it  remains  separated  from  the  walls 
of  the  pelvis,  and  cannot  come  in  contact  with  the  adjacent  soft 
parts  and  thus  undergo  healing. 

The  upper  limit  of  the  rectum  is  difficult  to  determine  with 
accuracy,  except  from  the  fact  that  it  is  separated  from  the  sig- 
moid flexure  by  a  slight  constriction  which  becomes  more  ap- 
parent when  attempts  are  made  at  dilatation.  From  this  upper 
point  it  gradually  expands  below  into  a  pouch,  the  ampulla, 
and  then  again  suddenly  contracts  under  the  grasp  of  the  mus- 
cles which  closes  its  lower  end. 


Pig.  1. — Exaggerated  Antero-posterior  Curve  of  the  Rectum. 


Curves. — The  curves  of  the  rectum  are  exceedingly  important 
in  a  practical  point  of  view.  There  are  two,  one  antero-pos- 
terior, the  other  lateral.  The  former  is  double.  From  above 
downward  it  follows  the  curve  of  the  sacrum  and  coccyx,  being 
concave  in  front,  and  convex  behind.  When  it  reaches  a  point 
opposite  the  tip  of  the  coccyx  it  suddenly  reverses  its  direction, 
turns  sharply  backward,  and  ends  at  the  anus  about  one  inch 
in  front  of  the  tip  of  that  bone. 

By  this  backward  curve  of  its  lower  end,  which  is  represented 
in  an  exaggerated  form  in  Fig.  1,  it  is  separated  from  the  vagina 
in  the  female,  and  from  the  urethra  in  the  male,  by  a  triangular 
space  having  its  base  at  the  perineum,  its  upper  wall  at  the 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  3 

vagina  or  urethra,  and  its  lower  at  the  upper  wall  of  the  rectum. 
The  angle  of  junction  of  these  two  curves  is  well  marked,  meas- 
uring from  twenty  to  thirty  degrees  ;  and  the  curve  is  not  with- 
out influence  in  the  function  of  defecation,  since,  by  it,  an  ob- 
struction is  formed  to  the  downward  course  of  the  faeces. 

The  lateral  curve  is  generally  a  single  one  from  left  to  right, 
starting  at  the  left  sacro-iliac  synchondrosis  and  ending  at  the 
median  line  at  a  point  opposite  the  third  sacral  vertebra,  from 
which  point  it  generally  passes  straight  on  to  the  anus.  This 
curve  may,  however,  pass  beyond  the  median  line  to  the  right 
in  its  lower  portion,  and  again  return  to  the  median  line  at  the 
anus.  It  is  subject  to  many  variations,  and  the  upper  portion 
may  be  more  or  less  twisted  on  itself  like  the  sigmoid  flexure. 

The  sigmoid  flexure  may  occupy  an  unnatural  position,  and 
the  rectum,  instead  of  commencing  at  the  left  sacro-iliac  junc- 
tion and  curving  toward  the  right,  may  commence  at  the  right 
and  curve  toward  the  left.  In  one  case,  reported  by  Cruveil- 
hier,1  where  the  sigmoid  flexure  was  in  the  natural  position,  the 
rectum  passed  almost  transversely  to  the  right  side  as  far  as  the 
right  sacro-iliac  junction,  and  then  returned  again  very  obliquely 
to  the  left  side. 

Divisions. — For  convenience  of  description  the  rectum  is 
usually  divided  into  three  portions,  named  first,  second,  and 
third,  from  below  upward.  The  first  extends  from  the  anus  to 
the  tip  of  the  prostate ;  is  about  an  inch  and  a  half  long ;  is 
firmly  closed  by  the  sphincters  ;  and  gives  attachment  to  a  por- 
tion of  the  levator  ani  muscle.  On  account  of  the  direction  of 
this  portion,  which  is  the  reverse  of  that  next  above,  the  finger 
should  never  be  passed  toward  the  sacrum,  or  even  directly  in- 
ward in  making  an  examination  ;  but  rather  toward  the  pubes. 
Bearing  this  simple  anatomical  point  in  mind  will  often  save  the 
patient  much  unnecessary  suffering.  The  second  portion  is  often 
described  as  reaching  from  the  apex  of  the  prostate  to  the  recto- 
vesical fold  of  peritoneum  ;  but,  as  the  point  of  duplicature  of 
the  peritoneum  is  not  only  variable  in  different  individuals,  but 
at  different  times  in  the  same  individual,  it  is  better  to  adopt  a 
fixed  bony  point,  as  the  third  piece  of  the  sacrum ;  in  which 
case  the  middle  portion  will  measure  about  three  inches  in 
length.     This  portion,  it  will  be  remembered,  is  convex  back- 

'Anat.  Path  ,  Amer.  Edition,  1844,  p.  377. 


4  DISEASES    OF   THE    RECTUM    AND    ANUS. 

ward,  following  the  curve  of  the  sacrum.  The  third  portion  ex- 
tends from  the  third  sacral  vertebra  to  the  left  sacroiliac  syn- 
chondrosis ;  its  lower  part  is  partially,  and  its  upper,  completely, 
surrounded  by  peritoneum,  which,  in  the  upper  part,  forms  the 
meso-rectum  attaching  it  to  the  sacrum. 

Relations. — The  most  important  surgical  relations  of  the  rec- 
tum are  on  the  anterior  surface.  The  first  portion  is  surrounded 
laterally  and  posteriorly  by  a  bed  of  connective  tissue,  rich  in 
fat  and  blood-vessels,  and  may,  therefore,  be  incised  on  either 
side,  or  backward,  with  comparative  safety.  In  front,  however, 
it  is  directly  in  relation  with  the  membranous  urethra  in  the 
male,  and  with  the  vagina  in  the  female  ;  though  at  the  anus  it 
is  separated  from  them  both  by  its  backward  and  downward 
course.  This  intimate  relationship  with  the  urethra  is  often 
taken  advantage  of  in  catheterism,  when  by  passing  the  finger 
into  the  rectum  the  tip  of  the  instrument  may  easily  be  felt ; 
and  it  also  explains  why  in  all  operations  on  the  urethra  or 
vagina  the  rectum  should  first  be  emptied  to  save  it  from  being 
wounded. 

In  the  second  portion  also,  the  lateral  and  posterior  surfaces 
have  no  special  surgical  relations  ;  while  the  anterior  is  in  direct 
contact  with  the  prostate,  the  base  of  the  bladder,  the  seminal 
vesicles,  and  sometimes,  at  its  upper  limit,  with  the  peritoneal 
fold  of  Douglas.  This  portion  is  closely  connected  with  the 
bladder  in  the  male,  and  with  the  vagina  in  the  female,  by  con- 
nective and  muscular  tissue  ;  and  the  two  cavities  may  easily 
be  made  to  communicate  by  any  morbid  process  or  by  a  sur- 
gical procedure.  It  was  at  this  point  that  the  trocar  was  plunged 
from  the  rectum  into  the  bladder  in  the  old  operation  of  punc- 
turing the  bladder  through  the  rectum  ;  and  Hyrtl '  speaks  of  a 
man  who  was  only  able  to  pass  his  water  after  first  introducing 
his  finger  into  the  rectum  and  raising  a  calculus  out  of  the  tri- 
gone of  the  bladder.  A  somewhat  analogous  case  is  reported  in 
which  a  long  slender  calculus  perforated  the  bladder  and  pro- 
jected into  the  rectum,  from  which  it  was  easily  removed.3  The 
prostate,  when  large,  may  project  over  the  sides  of  the  rectum, 
or  the  latter  may  receive  the  prostate  in  a  kind  of  groove  on  its 
upper  surface. 

The  third,  or  upper  portion,  unlike  the  other  two,  has  im- 

1  Topog.  Anat.,  ii.,  p.  103. 

■  Gooch  :  Chirurg.  Works,  London,  1792,  vol.  iii.,  p.  21C. 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  O 

portant  surgical  relations  on  every  side.  Posteriorly  it  is  in 
whole  or  part  covered  with  peritoneum  ;  and  is  separated  from 
the  sacrum  by  the  pyriformis  muscle,  the  sacral  plexus  of 
nerves,  and  the  branches  of  the  internal  iliac  artery.  On  its 
sides  it  is  in  contact  with  the  adjacent  convolutions  of  small  in- 
testine, and  lower  down,  with  the  levator  ani  muscle  and  the 
connective  tissue  of  the  ischio-rectal  fossa.  In  the  male  it  is  in 
relation,  in  front,  with  the  posterior  surface  of  the  bladder,  from 
which  it  is  separated  by  coils  of  small  intestine.  In  cases  of  re- 
tention either  of  urine  or  fseces  the  two  may  be  brought  into 
actual  contact.  In  the  female,  it  is  in  relation,  anteriorly,  with 
the  broad  ligament,  the  left  ovary  and  Fallopian  tube,  the 
uterus  and  vagina.  When  the  rectum  and  uterus  are  empty, 
the  coils  of  small  intestine  pass  down  between  them  to  the  bot- 
tom of  the  fold  of  Douglas,  and  they  may  even  escape  through 
the  posterior  wall  of  the  vagina  in  case  of  injury. 

From  these  relations  it  is  apparent  that  enlargements  and 
malpositions  of  the  uterus  may  act  directly  upon  the  rectum. 
The  vessels  may  be  so  obstructed  by  uterine  disease  as  to  cause 
hemorrhoidal  troubles,  or  interfere  with  operations  for  their  re- 
lief. The  rectum  may  be  entirely  occluded  by  the  pressure  of  a 
uterine  tumor  ;  and  a  hasty  examination  of  the  rectum  may  lead 
to  the  diagnosis  of  a  tumor  in  its  anterior  wall,  when  in  reality 
the  normal  uterus  alone  is  felt.  The  advantage  of  a  rectal  ex- 
amination in  all  doubtful  cases  of  pelvic  disease  is  also  manifest. 

Tlue  Anus. — The  rectum  terminates  below  in  the  anus  which 
is  tightly  closed  by  the  external  sphincter  muscle.  The  skin 
around  its  border  is  thin  and  pigmented,  covered  with  fine  hair 
in  the  male,  and  contains  a  great  number  of  sebaceous  follicles 
and  muciparous  glands.  The  skin  passes  deeply  into  the  anal 
orifice,  and  its  point  of  junction  with  the  mucous  membrane  is 
in  some  persons  indicated  by  an  indistinct  white  line.1  This 
white  line  of  junction  also  corresponds  to  the  division  be- 
tween the  external  and  internal  sphincter  muscles  ;  and  also  to 
the  point  at  which  many  of  the  terminal  filaments  of  the  inter- 
nal pudic  nerve  perforate  the  gut.  Both  skin  and  mucous  mem- 
brane at  the  anus  are  remarkable  for  the  development  of  erectile 
tissue ;  the  arteries  coming  from  the  inferior  hemorrhoidal, 
and  the   veins  being  very   numerous,  winding,    and  twisted. 

1  Hilton  :  Rest  and  Pain. 


6  DISEASES    OF    THE    RECTUM    AND    ANUS. 

The  presence  of  this  erectile  tissue  accounts  for  the  habit  of 
pederasty  which  will  occasionally  be  referred  to  as  a  cause  of 
rectal  disease.  It  is  a  habit  to  which  few  are  addicted  in  this 
country,  but  which  is  not  uncommon  in  some  other  parts  of  the 
world.  In  America  it  is  chiefly  seen  amongst  the  negro  race  and 
on  shipboard  amongst  sailors  who  are  on  a  long  voyage.  Among 
the  latter  it  was  a  vice  whose  existence  was  well  known  and 
which  was  occasionally  punished  by  the  officers  during  the  late 
war.  The  nerves  are  derived  both  from  the  cerebro-spinal  and 
sympathetic  systems,  as  will  be  shown  later. 

After  these  general  considerations  of  the  position  and  rela- 
tions of  the  rectum  as  a  whole,  the  individual  parts  may  be 
taken  up  more  in  detail.  The  rectal  wall  is  composed,  as  are 
the  other  parts  of  the  intestine,  of  four  layers  :  an  external  or 
peritoneal ;  a  muscular,  divided  into  longitudinal  and  circular  ; 
a  submucous  connective  tissue  layer ;  and  most  internally,  the 
mucous  membrane.  The  total  thickness  of  these  coats  collect- 
ively varies  greatly  in  different  subjects,  the  variation  being 
chiefly  in  the  muscular  coat,  the  others  remaining  pretty  con- 
stantly of  the  same  thickness. 

Peritoneum. — The  upper  portion  of  the  rectum  is  entirely 
surrounded  by  peritoneum,  and  has,  besides,  a  fold  of  attach- 
ment to  the  anterior  face  of  the  sacrum,  known  as  the  meso- 
rectum.  The  meso-rectum  is  about  four  inches  long,  blends 
with  the  meso-colon  above,  and  extends  down  as  low  as  the 
third  or  fourth  sacral  vertebra,  from  which  point  its  two  layers 
are  reflected  over  the  sides  and  anterior  surface  of  the  rectum 
on  to  the  posterior  wall  of  the  uterus  and  upper  limit  of  the 
vagina  in  the  female  ;  and  on  to  the  bladder  in  the  male,  form- 
ing the  cul-de-sac  of  Douglas.  The  meso-rectum  may  be  so 
short  as  to  disappear  when  the  rectum  is  distended,  or  it  may 
be  entirely  absent  ;  in  which  case  the  peritoneum  passes  directly 
from  the  sides  of  the  rectum  to  the  sacrum.  Between  its  two 
layers  may  be  found  some  loose  connective  tissue,  the  hsemor- 
rhoidal  vessels  and  nerves,  and  the  lymphatics. 

In  passing  from  the  limit  of  the  meso-rectum  behind,  to  form 
the  cul-ds-sac  in  front,  the  peritoneum  covers  more  or  less  of 
the  lateral  and  anterior  surfaces  of  the  middle  portion  of  the 
rectum.  As  before  mentioned,  the  point  at  which  the  peritoneum 
leaves  the  anterior  surface  of  the  middle  portion  of  the  rectum 
to  be  reflected  upon  the  posterior  surface  of  the  bladder  in  the 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  7 

male,  or  of  the  vagina  or  uterus  in  the  female,  varies  in  different 
subjects,  and  at  different  times  in  the  same  subject ;  and  hence 
the  differences  in  its  distance  from  the  anus  as  given  in  different 
works  on  anatomy.  In  new-born  children  the  bottom  of  the 
cul-de-sac  touches  the  upper  edge  of  the  prostate  and  ap- 
proaches to  within  about  an  inch  of  the  anus.  At  five  years  it 
rises  in  the  pelvis  with  the  development  of  the  seminal  vesicles 
and  internal  organs  of  generation ;  and  in  old  people  with  en- 
largement of  the  prostate,  it  is  carried  still  higher.  In  women 
it  generally  extends  to  the  upper  border  of  the  posterior  vaginal 
wall ;  so  that  the  latter  is  separated  from  the  rectum  by  peri- 
toneum for  about  one-third  of  an  inch.  By  every  expansion  of 
the  bladder  or  rectum  as  well  as  by  tumors  of  the  pelvis,  the  fold 
is  carried  further  away  from  the  anus,  as  may  easily  be  demon- 
strated on  the  cadaver  by  forcible  injections  of  the  bladder. 

The  average  distance  from  the  anus  of  the  point  at  which 
the  serous  coat  leaves  the  anterior  wall  of  the  rectum  is,  there- 
fore, very  difficult  to  determine  ;  and  yet  it  is  of  the  greatest 
importance  in  all  surgical  operations  on  the  part ;  since  the  fact 
of  opening  or  not  opening  the  peritoneal  cavity  may  make  all 
the  difference  between  life  and  death  in  the  result  of  an  opera- 
tion. Dupuytren  gives  the  distance  as  seventy  mm.,  and  less 
when  the  organs  are  empty ;  Lisfranc  gives  six  inches  in  the 
female,  and  four  in  the  male,  but  does  not  state  in  what  condi- 
tion of  the  organs  the  measurements  are  taken  ;  Sappey,  Vel- 
peau,  and  Legendre  give  five  and  a  half  ctm.  when  the  bladder 
is  empty  and  eight  when  distended  ;  Quain  says  four  inches  ; 
Allingham  from  two  to  five  or  more.  Cripps,1  acting  on  the 
idea  that  the  fold  is  not  easily  displaced  downward  by  traction 
on  the  rectum,  has  experimented  by  filling  the  peritoneal  cavity 
with  plaster,  and  then  thrusting  a  needle  through  the  skin  of 
the  perineum  till  its  point  struck  the  plaster.  In  this  way  he 
has  obtained  an  average  measurement  of  two  and  a  half  inches 
when  the  bladder  and  rectum  are  both  empty,  and  an  additional 
inch  when  distended.2 

1  Cancer  of  the  Rectum.     London,  1880,  p.  129. 

2  The  following  authors  give  the  following  measurements  :  Malgaigne,  males,  6-8 
ctm.  ;  females,  4-6  ctm.  Luschka,  5.5-8  ctm.  Hyrtl,  8  ctm.  Lisfranc  and  Sanson,  11 
ctm.  Richet,  males,  10.8  ctm.  ;  females,  16.2  ctm.  Blaudin,  males,  8.1  ctm.  ;  females, 
4  1  ctm.  Ferguson,  males,  10.5  ctm.  ;  females,  15.4  ctm.  Esmarch  :  Die  Krankheiten 
des  Mastdarms  und  des  Afters.     Pitha  u.  Billroth  :   Chirurgie,  p.  7. 


8  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Muscular  Coat. — In  the  fact  that  the  muscular  coat  is 
arranged  in  two  layers,  an  external  longitudinal  and  an  in- 
ternal circular,  the  rectum  resembles  the  other  portions  of  the 
alimentary  canal ;  but  in  the  further  arrangement  of  its  hbres 
it  resembles  the  oesophagus  more  closely  than  the  intermediate 
portions.  The  fibres  are  spread  out  into  two  uniform  layers, 
and  are  not  arranged  in  bands  crossing  each  other  in  basket 
network  and  leaving  sacculi  between  the  meshes  as  in  the  large 
intestine. 

The  longitudinal  fibres  are  the  direct  continuation  of  the 
three  longitudinal  bands  of  the  large  intestine.  Upon  reaching 
the  rectum,  these  blend  into  one  continuous  sheath  which,  how- 
ever, is  somewhat  heavier  on  the  anterior  surface  of  the  bowel 
than  on  any  other.  At  the  point  of  contact  of  the  rectum  with 
the  bladder  and  prostate  these  fibres  are  in  part  reflected  with 
the  peritoneum  on  to  the  posterior  wall  of  the  latter  and  thus 
form  a  firm  band  of  union  between  the  two  organs,  as  has  been 
particularly  described  by  Dr.  Garson.1  They  have  been  named 
by  him  the  recto-vesical  fibres. 

The  ending  of  the  longitudinal  fibres  is  worthy  of  note.  Ac- 
cording to  Horner,'  when  they  reach  the  lower  margin  of  the 
internal  sphincter  a  part  of  them  turn  upward  between  it  and 
the  external  sphincter  and  ascend  for  an  inch  or  two  in  contact 
with  the  mucous  coat  into  which  they  are  finally  inserted  ; 
having,  therefore,  an  obvious  influence  in  causing  protrusion  of 
the  mucous  membrane.  In  the  lower  fourth  of  their  extent, 
these  fibres  become  weaker  and  less  distinct,  and  some  of  them 
finally  blend  into  elastic  tendinous  tissue  which  passes  between 
the  bundles  of  the  external  sphincter,  and  is  inserted  into  the 
subcutaneous  connective  tissue  of  the  anus.  Others  are  inserted 
posteriorly  by  means  of  an  elastic  tendon  about  an  inch  long 
into  the  anterior  sacro-coccygeal  ligament — an  arrangement 
pointed  out  by  Luschka3  as  analogous  to  what  is  found  in  most 
mammalia,  in  whom  a  considerable  number  of  the  longitudinal 
fibres  are  inserted  into  the  base  of  the  coccyx,  giving  a  fixed 
point  for  the  rectum  in  defecation. 

The  circular  layer  is  reinforced  at  certain  points,  notably  at 

1  The  Arrangement  and  Distribution  of  the  Muscular  Fibres  of  the  Rectum.    Paper 
read  before  the  Brit.  Med.  Assoc.     Reported  in  Brit.  Med.  Jour.,  September  6,  1879. 
8  A  Treatise  on  Special  and  General  Anatomy.     Vol.  ii.,  p.  40,  Philadelphia,  1826. 
a  Anat.  des  Menachen.     Vol.  ii. ,  part  2,  p.  208. 


POINTS   IN    ANATOMY    AND    PHYSIOLOGY.  9 

the  internal  sphincter  which  is  merely  a  collection  of  these 
fibres,  and  at  a  point  higher  up  where  they  are  again  gathered 
into  a  bundle  either  partly  or  completely  surrounding  the 
bowel,  known  as  the  third  sphincter.  This  muscle  will  be  de- 
scribed more  fully  later. 

Submucous  Coat. — The  submucous  tissue  forming  the  bed 
upon  which  the  mucous  membrane  rests  is  sufficiently  lax  to 
permit  of  considerable  sliding  of  the  mucous  membrane  on  the 
muse  alar  coat.  In  it  the  blood-vessels  ramify,  and  from  it  per- 
pendicular processes  are  given  off  which  perforate  both  the 
internal  and  external  muscular  layers  and  are  finally  lost  in  the 
sheaths  of  the  muscular  fibres,  or  go  entirely  through  the  mus- 
cular layer  and  blend  with  the  fibrous  stroma  of  the  surround  - 


Fig.  2. — Section  of  the  Normal  Rectal  Wall.     (Cripps.) 

ing  fatty  tissue.  These  processes  from  the  submucous  tissue, 
together  with  the  lymph  and  blood-vessels,  serve  to  bind  the 
various  layers  of  the  rectal  wall  together.1     See  Fig.  2. 

Mucous  Membrane. — The  mucous  membrane  of  the  rectum 
corresponds  in  its  general  characters  with  that  of  the  other 
parts  of  the  bowel,  being  modified,  however,  in  certain  particu- 
lars to  suit  its  location  and  function.  Its  thickness  is  about 
three-quarters  of  a  mm.  ;  it  is  redder  and  more  vascular  than 
that  of  other  parts  of  the  large  intestine  ;  it  glides  freely  on  the 
tissue  beneath,  and  is  so  ample  as  to  be  gathered  into  folds  at 
various  points  which  are  of  considerable  surgical  and  anatom- 
ical interest.  At  its  point  of  union  with  the  skin  of  the  anus, 
it  is  gathered  into  vertical  folds  which  diminish  when  the  bowel 
is  distended,  but  do  not  entirely  disappear,  and  hence  are  not 

1  Cripps,  op.  cit. ,  p.  38. 


10 


DISEASES    OF   THE    EECTUM    AND    ANUS. 


due  solely  to  the  contraction  of  the  sphincter.  These  vertical 
folds  have  received  the  name  of  columna  recti,  or  columns  of 
Morgagni ;  and  Treitz  states  that  they  contain  bands  of  mus- 
cular fibres  running  longitudinally  and  terminating  above  and 
below  in  elastic  tissue.  Kohlrausch  1  also  describes  a  thin  layer 
of  longitudinal  muscular  fibres  under  the  mucous  membrane  at 
this  point  and  has  named  it  the  sustentator  tunicce  mucosa  ; 
but  most  anatomists,  with  Henle,  have  failed  to  find  anything 
more  than  the  stratum  of  muscular  tissue  common  to  the  whole 
mucous  coat,  and  known  as  the  muscularis  mucosae. 


Fig.  3. — Section  of  the  Rectal  Mucous  Membrane.  (Esmarch.)  1.  Follicles  of  Lieberkuhn. 
2.  Muscular  layer  of  mucous  membrane.  3.  Submucous  connective  tissue  and  vessels,  with  a 
solitary  closed  follicle,  over  which  the  tubular  follicles  are  wanting- 

Between  the  lower  ends  of  the  columnce  recti  little  arches 
are  stretched  from  one  to  the  other,  forming  pouches  of  skin 
and  mucous  membrane.  These  are  more  developed  in  old 
people,  and  may  retain  small  pieces  of  hardened  faeces  or  for- 
eign bodies  in  their  cavities,  which  are  directed  upward  and 
thus  give  rise  to  suppuration  and  abscess. 

The  mucous  membrane  may,  for  the  purpose  of  study,  be 
divided  into  three  separate  layers,  the  muscular,  glandular,  and 
epithelial.     Fig.  3. 

The  muscular  layer  {muscularis  mucoso3,  sustentator  tu- 
nica mucosa:)  is  a  layer  of  unstriped  muscular  tissue  about 
0.02  mm.  thick,  which  is  everywhere  found  in  the  deepest  layer 
of  the  mucous  membrane,  extending  from  the  oesophagus  to  the 
rectum,  but  is  more  strongly  developed  in  the  region   of  the 

1  Anat.  u.  Physiol,  der  Beckenorgane,  Leipzig,  1854.  Boyer  also  says  they  are 
strengthened  by  muscular  fibres.     Traitu  d'Anat.,  T.  iv.     Paris,  1815. 


POINTS    IN    ANATOMY    AND   PHYSIOLOGY.  11 

anus  where  it  serves  to  hold  the  membrane  in  place  and  prevent 
prolapse.  It  consists  of  bundles  running  in  some  parts  both 
longitudinally  and  circularly,  and  in  others  in  one  direction 
only  ;  and  which  send  prolongations  up  between  the  glands  to 
the  villi. 

The  glandular  layer  is  about  0.07  mm.  in  thickness.  It  con- 
sists of  a  layer  of  Lieberkuhn's  follicles,  with  an  occasional 
solitary  closed  follicle  below  them,  the  situation  of  which  is 
marked  by  a  slight  depression  in  the  mucous  membrane,  and  an 
absence  of  the  tubular  follicles  at  that  point.  The  follicles  are 
tubular  depressions  arranged  with  great  regularity  and  set  so 
closely  together  that  the  width  of  the  intervening  tissue  is,  On 
the  average,  about  one-sixth  the  diameter  of  the  follicle.  The 
length  of  the  tubes  is  four  or  five  times  their  diameter,  the  re- 
spective measurements  being:  length,  0.35  mm.  ;  diameter,  0.08 
mm.  These  tubular  depressions  or  follicles  are  lined  with  epi- 
thelial cells  arranged  with  their  bases  resting  on  the  connective 
tissue  and  their  apices  free  in  the  cavity  of  the  follicle  ;  and  the 
cells  of  one  follicle  are  directly  continuous  with  those  of  the 
next,  hanging  freely  into  the  lumen  of  the  bowel  as  they  pass 
over  from  one  depression  into  the  next.  The  appearance  of  the 
cells  is  analogous  to  that  of  a  bee's  honeycomb,  the  intervening 
wall  being  common  to  two  cells.  The  intertubular  tissue  con- 
sists of  a  fine  trabecular  network,  the  meshes  of  which  are  very 
long  in  the  vertical  direction  running  parallel  to  the  follicle 
(Cripps). 

The  follicles  of  Lieberkuhn  are  simply  inverted  villi,  and 
answer  the  same  purpose  of  absorption.  There  are  good  reasons 
for  the  substitution  of  follicles  for  villi  in  this  part  of  the  canal, 
the  former  being  less  subject  to  injury  from  hardened  faeces, 
and  the  fact  of  such  substitution  gathers  great  weight  from  the 
fact  that  in  certain  cases  where  an  artificial  anus  has  been  estab- 
lished, the  whole  bowel  below  that  point  has  been  found  in 
after  years  covered  with  a  growth  of  villi.1 

Muscles  of  the  Rectum  and  Anus. — The  muscles  which  may 
properly  be  included  in  a  description  of  the  rectum  and  anus 
are  the  external  and  internal  sphincters,  the  levator  ani,  ischio- 
coccygeus,  retractor  recti  or  recto-coccygeus,  and  the  transver- 
sus  perinei. 

1  Specimen  No.  1,288,  Museum  of  College  of  Surgeons  (Cripps). 


12  DISEASES    OF   THE    RECTUM    AND    ANUS. 

External  Sphincter. — The  external  sphincter  muscle  is  a  thin 
layer  of  voluntary  fibres,  about  half  an  inch  broad  on  each  side 
of  the  anus,  surrounding  it  in  the  form  of  an  ellipse,  and  having 
a  narrow  pointed  insertion  anteriorly  and  posteriorly.  It  is 
situated  immediately  beneath  the  skin,  and  extends  about  two 
centimetres  up  the  bowel,  where  its  upper  limit  may  sometimes 
be  seen  by  the  white  line  already  mentioned.  It  is  divided  into 
a  superficial  and  deep  portion.  The  superficial  is  inserted  both 
in  front  and  behind  into  the  subcutaneous  cellular  tissue.  The 
deeper  and  thicker  portion  is  inserted  posteriorly  by  a  narrow 
flat  tendon  into  the  posterior  surface  of  the  fourth  coccygeal 
vertebra.  Between  the  tendon  and  the  bone  is  a  bursa  about 
the  size  of  a  pea — bursa  mucosa  coccygea  of  Luschka.  An- 
teriorly it  is  inserted  into  the  central  tendon  of  the  perineum  in 
common  with  the  transversus  perinei  and  bulbo-cavernosus,  and 
in  women  with  the  sphincter  vaginae.  The  action  of  the  muscle 
is  to  close  the  anus  and,  under  the  control  of  the  will,  to  antag- 
onize the  proper  dilators  of  the  anus,  the  levator  ani  and  ischio- 
coccygeus,  as  well  as  the  peristaltic  action  of  the  bowel  and  the 
contraction  of  the  diaphragm.  The  superficial  band  of  fibres 
acts  only  in  puckering  the  skin.  The  nerve-supply  comes  from 
the  hemorrhoidal  branch  of  the  internal  pudic,  and  the  hemor- 
rhoidal branch  of  the  fourth  sacral  nerve. 

Internal  Sp7ii?icter. — The  internal  sphincter  is  situated  im- 
mediately above  and  partly  within  the  deeper  portion  of  the 
external  sphincter  ;  being  separated  from  it  by  a  layer  of  fatty 
connective  tissue.  Its  thickness  is  about  two  lines  ;  its  vertical 
measurement  from  half  an  inch  to  an  inch  ;  and  it  is  a  direct 
continuation  of  the  involuntary  circular  fibres  of  the  bowel, 
growing  thicker  and  stronger  as  it  approaches  the  anus.  It 
also  is  supplied  by  the  hemorrhoidal  branch  of  the  internal 
pudic. 

Recto-coccygeus  (Retractor  recti,  Treitz ; '  Tensor  Fascise 
Pelvis,  Kohlrausch). — This  muscle  consists  of  two  flat  lateral 
bands  of  unstriped  fibres,  each  of  which  is  about  four  mm. 
broad,  which  diverge  at  an  acute  angle  from  the  anterior  coccy- 
geal ligament  at  the  tip  of  the  coccyx,  and  passing  forward  and 
downward,  embrace  the  lower  end  of  the  rectum  on  each  side 


1  Vierteljahrsschrift  f.  praktische  Heilkunde.     Prag.  1803,  Bd.  i.,  S.  124.     Henle: 
AbbUdung  2,  183. 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  13 

like  a  fork.  It  is  located  directly  under  that  portion  of  the 
levator  ani  which  forms  the  floor  of  the  pelvis  between  the  tip 
of  the  coccyx  and  the  anus  ;  and  blends  partly  with  the  longi- 
tudinal muscular  fibres  of  the  rectum,  and  partly  with  the  pel- 
vic fascia  surrounding  its  end.  Its  function  is  to  hold  the  end 
of  the  rectum  against  the  coccyx  and  to  give  it  a  fixed  point  in 
defecation. 

Levator  Ani. — The  levator  ani  and  ischio-coccygeus  muscles 
form  a  true  diaphragm  to  the  pelvis  by  giving  an  uninterrupted 
muscular  and  tendinous  plane  from  the  lower  border  of  the 
pyriformis,  behind,  to  the  arch  of  the  pubes  in  front.  That  part 
which  is  named  ischio-coccygeus  is  usually  described  as  a  sepa- 
rate muscle,  though  in  no  way  differing  in  function  from  the 
larger  portion,  and  only  distinguishable  from  it  by  its  more 
tendinous  structure.  It  is  situated  just  in  front  of  the  sacro- 
sciatic  ligaments,  and  arises  by  aponeurotic  fibres  from  the  sides 
and  tip  of  the  spine  of  the  ischium,  from  the  anterior  surface  of 
the  lesser  sacro-sciatic  ligament,  and  often  from  the  posterior 
part  of  the  pelvic  fascia.  It  is  inserted,  also  by  aponeurotic 
fibres,  into  the  border  of  the  coccyx  and  lower  part  of  the 
border  of  the  sacrum.  Owing  to  its  tendinous  origin  and  inser- 
tion, the  greater  part  of  the  muscle  is  composed  of  aponeurotic 
fibres.  It  is  in  relation  superiorly,  by  its  concave  surface,  with 
the  rectum ;  inferiorly,  by  its  convex  surface,  with  the  sacro- 
sciatic  ligaments  and  the  gluteus  maximus  ;  posteriorly,  its 
border  is  in  contact  with  the  lower  border  of  the  pyriformis  ; 
and  anteriorly,  it  is  directly  continuous  with  the  fibres  of  the 
levator  ani.  Its  action  is  to  draw  the  coccyx  to  its  own  side,  or, 
when  both  muscles  act  together,  to  fix  that  bone  and  prevent 
its  being  thrown  backward  in  defecation.  It  probably  has  no 
such  action  as  would  justify  the  name  of  levator  coccygis,  given 
it  by  Morgagni.  Its  nerve-supply  is  from  the  anterior  branch 
of  the  fourth  sacral  nerve. 

The  levator  ani  proper,  which  constitutes  the  remaining  por- 
tion of  the  pelvic  diaphragm,  is  in  its  general  shape  an  inverted 
cone,  supporting  the  pelvic  contents  in  its  cavity  and  allowing 
the  rectum  and  prostate  to  pass  through  its  apex.  Considering 
each  lateral  half  of  the  muscle  apart,  we  find  it  made  up  of  a 
delicate  layer  of  muscular  fibres  forming  a  thin,  curved,  and 
quadrilateral  sheet,  broader  behind  than  in  front.  Its  upper 
border  is  stretched  across  the  pelvis  from  the  pubes  to  the  spine 


14  DISEASES    OF    THE    RECTUM    AND    ANUS. 

of  the  ischium,  arising  from  both  these  bony  points  and  from 
the  tendinous  line  of  union  of  the  pelvic  with  the  obturator 
fascia,  which  runs  antero-posteriorly  between  them.  Its  attach- 
ment to  the  pubic  bone  is  at  a  point  on  its  inner  surface,  near 
the  middle  of  the  descending  ramus  and  a  little  to  one  side  of 
the  symphysis.  This  attachment  will  be  found  to  vary  some- 
what in  different  dissections,  being  sometimes  a  little  higher  or 
a  little  lower  on  the  bone,  and  sometimes  on  the  cartilage  be- 
tween the  bones.  The  muscular  fibres  may  also  be  traced  at 
times  upward  into  the  pelvic  fascia  above  its  junction  with  the 
obturator. 

From  this  extensive  though  delicate  and  in  great  part  mem- 
branous origin,  the  fibres  proceed  downward  and  inward  toward 
the  median  line.  Those  most  anterior  unite  with  those  of  the 
opposite  side  beneath  the  neck  of  the  bladder,  the  prostate,  and 
the  adjacent  portion  of  the  urethra.  These  fibres  are  concealed 
by  the  pubo-prostatic  ligament  or  anterior  fold  of  the  recto- 
vesical fascia,  from  which  they  also  sometimes  take  origin  in 
part.  They  are  in  relation,  in  front,  with  the  posterior  surface 
of  the  triangular  ligament.  This  portion  is  sometimes  separated 
from  the  main  body  of  the  muscle  by  a  cellular  interval,  similar 
to  those  often  found  in  other  parts  of  this  thin  muscular  sheet. 

The  fibres  which  arise  from  the  tip  of  the  spine  of  the  is- 
chium are  inserted  into  the  side  of  the  tip  of  the  coccyx,  while 
the  fibres  immediately  in  front  of  these  (precoccygeal)  unite 
with  those  of  the  opposite  side  in  the  median  line  and  form  a 
raphe  which  extends  from  the  point  of  the  coccyx  to  the  pos- 
terior border  of  the  sphincter  and  thus  complete  the  floor  of  the 
pelvis. 

The  fibres  which  arise  indirectly  from  the  upper  part  of  the 
obturator  foramen  and  from  the  brim  of  the  pelvis  by  means  of 
the  pelvic  fascia,  pass  downward  and  inward,  forming  a  curve 
with  its  concavity  upward,  and  may  be  divided  into  vesical  and 
anal.  The  vesical  pass  into  the  sides  of  the  bladder.  The  anal 
fibres  in  part  pass  backward  and  meet  behind  the  bowel  and  in 
part  blend  with  those  of  the  external  sphincter  at  its  upper 
border,  there  being  no  distinct  line  of  separation  between  the 
two  muscles. 

The  relations  of  the  levator  ani  are  of  great  surgical  impor- 
tance. Superiorly  its  surface  is  covered  by  the  superior  pelvic 
fascia  (the  recto-vesical  layer  of  the  pelvic  fascia)  which  sepa- 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  15 

rates  it  from  the  peritoneum  and  pelvic  organs.  The  space  be- 
tween this  fascia  and  the  peritoneum  is  the  superior  pelvi-rectal 
space  of  Richet.  See  Fig.  65,  page  199.  Its  inferior  surface  is 
separated  from  the  obturator  internus  muscle  by  the  obturator 
fascia,  and  beneath  this  is  the  ischio-rectal  fossa.  The  posterior 
part  of  the  muscle  is  in  relation  with  the  gluteus  maximus. 

The  actions  of  this  muscle  are  various.  First,  it  acts  as  a 
support  to  the  pelvic  organs,  and  antagonizes  the  diaphragm 
and  abdominal  muscles  when  they  act  upon  the  abdominal  con- 
tents. Again,  it  prevents  the  rectum  from  being  protruded, 
and  raises  the  anus  and  opens  it,  being  in  this  respect  the  direct 
antagonist  of  sphincter.  By  inclosing  the  neck  of  the  bladder 
the  muscle  acts  upon  it  also,  and  in  the  act  of  defecation  when 
the  muscle  is  contracted  to  open  the  anus,  the  neck  of  the 
bladder  is  pressed  upon  and  the  urethra  closed.  In  this  way  is 
explained  the  well-known  difficulty  of  passing  urine  and  faeces 
at  the  same  time.  By  inclosing  the  bladder,  vesiculse  seminales, 
prostate,  and  rectum  in  its  grasp,  the  muscle  produces  a  sym- 
pathy among  these  parts  which  will  often  be  found  very  dis- 
tressing in  diseases  of  the  rectum  or  after  operations  for  their 
relief — such  as  impossibility  of  micturition,  erections,  and  lan- 
cinating pain  due  to  spasmodic  action  of  the  muscle.  It  will 
often  happen  that  after  a  complete  paralysis  by  free  division  of 
both  sphincter  muscles  in  an  operation  upon  the  rectum,  the 
patient  will  still  complain  of  a  sharp  spasmodic  pain  at  inter- 
vals— just  such  a  pain  as  is  caused  by  spasmodic  contractions  of 
the  sphincter.  In  such  cases  it  is  the  levator  ani  which  is  at 
fault.  The  muscle  also  aids  the  longitudinal  fibres  of  the  rec- 
tum in  their  opposition  to  the  dragging  of  the  faeces  ;  and  the 
anal  fibres  also  draw  the  rectum  upward  and  forward,  and  com- 
press it  on  the  sides,  and  thus  aid  in  the  expulsion  of  its  con- 
tents. 

The  muscle  receives  a  filament  from  the  fourth  sacral  nerve 
on  its  pelvic  surface,  and  another  from  the  internal  pudic. 

Transversus  Perinei. — This  also  has  an  action  in  defecation. 
Its  fibres  do  not  always  blend  with  those  of  the  opposite  side  in 
the  median  raphe,  but  the  two  muscles  are  sometimes  continu- 
ous, traversing  the  anterior  extremity  of  the  external  sphincter. 
In  such  a  case  the  two  muscles  form  a  continuous  half  ring  the 
concavity  of  which  is  directed  backward  and  embraces  the  an- 
terior part  of  the  rectum,  assisting  powerfully  in  defecation  by 


16  DISEASES    OF    THE    EECTUM    AND    ANUS. 

pressing  the  anterior  against  the  posterior  wall  of  the  bowel  in 
conjunction  with  the  external  sphincter  (Cruveilhier). 

Arteries. — The  rectum  is  supplied  with  blood  from  five  arter- 
ies, one  single  and  two  pairing. 

The  superior  hsemorrhoidal  is  single  and  is  a  direct  branch 
of  the  superior  mesenteric.  It  is  the  direct  continuation  of  the 
parent  trunk,  passing  into  the  pelvis  behind  the  rectum  in  the 
fold  of  the  meso-rectum,  and  dividing  into  two  branches  which 
extend,  one  on  each  side  of  the  bowel,  to  its  lower  end.  About 
five  inches  from  the  anus  these  subdivide  into  smaller  branches 
about  seven  in  number,  which  pierce  the  muscular  coat  about 
two  inches  lower  down.  They  then  descend  between  the  mucous 
and  muscular  layers  at  regular  intervals  to  the  end  of  the  bowel, 
where  they  communicate  in  loops  opposite  the  internal  sphinc- 
ter, and  anastomose  with  the  terminal  filaments  of  the  middle 
and  inferior  hsemorrhoidal  arteries. 

The  middle  hsemorrhoidal  arteries — one  on  each  side — are 
not  constant  in  their  origin,  sometimes  coming  from  the  hypogas- 
tric or  the  inferior  vesical,  and  sometimes  from  other  sources. 

The  inferior  hsemorrhoidal  arteries — also  pairing — are  usually 
given  off  from  the  internal  pudic  near  the  point  where  it  crosses 
the  tuber  ischii.  They  cross  through  the  fat  of  the  ischio-rectal 
fossse  and  are  distributed  with  the  middle  hsemorrhoidal  to  the 
lowest  part  of  the  rectum  and  to  the  anus  and  adjacent  skin. 

Veins. — There  are  three  sets  of  rectal  veins,  as  there  are  three 
sets  of  arteries,  the  superior,  middle,  and  inferior ;  and  these 
are  so  arranged  as  to  form  two  distinct  venous  systems,  the  one, 
rectal,  and  returning  its  blood  to  the  vena  portse ;  the  other, 
anal,  returning  its  blood  through  the  internal  iliac.  The  first, 
or  rectal  circulation,  is  made  up  of  the  superior  hsemorrhoidal 
vein  ;  the  second,  or  anal,  is  made  up  of  the  middle  and  inferior 
hsemorrhoidal  veins ;  the  middle  receiving  its  blood  from  the 
anus  and  the  inferior  from  the  adjacent  integument.  The  mid- 
dle hsemorrhoidal  ascends  obliquely  into  the  ischio-rectal  fossa  ; 
the  inferior  starts  horizontally  from  the  skin  of  the  anus  and 
empties  into  the  internal  pudic. 

The  middle  hsemorrhoidal  is  formed  from  two  venous  trunks, 
one  on  the  anterior,  the  other  on  the  posterior  aspect  of  the  rec- 
tum, which  by  anastomosing  with  the  corresponding  branches 
from  the  opposite  side  surround  the  sphincter  in  a  venous  cir- 
cle.   From  this  circle  spring  the  collateral  branches,  which  by 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY. 


17 


their  successive  division  and  anastomoses  form  a  true  venous 
plexus.  The  inferior  hemorrhoidal  vein  also  has  a  plexiform 
arrangement  at  its  origin,  but  its  branches  are  situated  between 
the  skin  and  the  inferior  border  of  the  external  sphincter.  The 
rectal  pouch  is  not,  therefore,  supplied  with  blood  from  the  ex- 
ternal hemorrhoidal  veins,  but  only  the  anus  and  the  region  of 
the  sphincters. 


YHM. 


YHM. 


VHE 


Fig.  4.— Rectal  Veins  seen  from  without.  (Duret.)1  Amp.,  rectal  pouch;  S.  E.,  external 
sphincter  ;  P.,  skin  at  margin  of  anus  dissected  up  and  turned  back  ;  V.  H.  I.,  internal  hem- 
orrhoidal vein  ;  V.  H.  M.,  middle  hsemorrhoidal  vein ;  V.  H.  E.,  external  hEemorrhoidal' vein. 

When,  on  the  other  hand,  the  venous  circulation  of  the  rec- 
tum proper  is  injected  from  the  inferior  mesenteric  vein,  three 
or  four  large  venous  trunks  may  be  seen  on  the  external  surface 
of  the  rectum  ascending  on  the  sides  and  posteriorly.  Figs  4 
and  5.     These  veins  make  their  appearance  suddenly  by  five  or 


1  "  Recherches  sur  la  Pathogenic  des  Hemorrhoides  : "  Arch.   Gen.  de  Med.,  De- 
cember, 1879. 
2 


IS 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


six  branches,  which  perforate  the  wall  of  the  bowel  about  three 
inches  from  the  margin  of  the  aims.  If  the  rectum  be  opened 
longitudinally  and  the  mucous  membrane  dissected  up  to  a  suf- 
ficient height  (about  four  inches),  it  will  be  seen  that  these  five 
or  six  large  veins,  already  visible  on  the  outside  of  the  bowel, 
come  from  within,  and  that  they  have  already  pursued  quite  a 

H.I 


Fio.  5. — Rectal  Veins  seen  from  within.  (Duret.)  M.  q.,  mucous  membrane  dissected  up 
and  cut  away  below;  M.  cl.,  muscular  tunic;  Sp.  I,  internal  sphincter;  Sp.  E.,  external 
sphincter;  P.,  skin  ;  H.  I.,  internal  haemorrhoidal  vein  ;  H.  M.,  middle  haemorrhoidal  vein  ; 
V.  H.  E.,  external  hemorrhoidal  vein. 


long  course  under  the  mucous  membrane.  They  are  formed  by 
collateral  branches,  and  especially  by  about  a  dozen  primitive 
branches,  which  originate  about  half  an  inch  above  the  anus 
and  ascend  in  parallel  and  flexuous  lines  for  several  centimetres 
to  unite  into  common  trunks.  Each  of  these  little  ascending 
branches  has  its  origin  in  a  minute  pool  of  blood,  the  size  of 


POINTS    IN    ANATOMY   AND    PHYSIOLOGY.  19 

which  varies  in  the  normal  state  from  that  of  a  grain  of  wheat 
to  that  of  a  small  pea. 

These  little  sacs  are  arranged  in  a  circular  form  aronnd  the 
extremity  of  the  rectum.  If  carefully  dissected  they  may  be 
seen  to  be  connected  with  the  little  veins  before  mentioned,  and 
also  with  another  little  vein  which  perforates  the  internal 
sphincter  near  its  lower  edge,  and  empties  into  one  of  the  rudi- 
mentary branches  of  the  external  hemorrhoidal  plexus.  Many 
of  these  little  communicating  branches  between  the  external 
and  internal  hemorrhoidal  systems  pass  through  the  substance 
of  the  external  sphincter.  It  results  from  this,  that  when  the 
external  sphincter  is  contracted,  the  anastomosis  between  the 
two  systems  is  prevented. 

Verne uil  has  laid  stress  upon  the  fact  that  where  the  in- 
ternal or  superior  hemorrhoidal  veins  perforate  the  rectal  wall 
from  within  outward,  they  pass  through  "muscular  button- 
holes" surrounded  by  no  fibrous  tissue  and  having,  therefore, 
the  power  of  contracting  round  the  vein,  closing  its  calibre,  and 
preventing  the  return  of  blood  to  the  liver.  In  this  anatomical 
arrangement  he  believes  he  has  found  the  active  cause  of  in- 
ternal haemorrhoids. 

The  disposition  of  the  rectal  veins  into  two  distinct  systems, 
the  one  internal  and  the  other  external,  is  fully  in  conformity 
with  our  knowledge  of  the  development  of  the  rectum  and 
anus.  The  rectal  cul-de-sac  is  at  first  situated  at  some  distance 
from  the  perineum,  and  as  it  descends  it  carries  with  it  its  own 
proper  vascular  supply.  The  anal  depression  is  of  necessity 
provided  with  an  independent  set  of  veins,  and  when  the  rec- 
tum and  anus  are  finally  united  into  one  canal  the  two  venous 
systems  also  unite. 

The  internal  hemorrhoidal  veins  also  communicate  freely 
with  other  branches  of  the  internal  iliac  around  the  trigone  of 
the  bladder  by  means  of  minute  branches  from  one-half  to  one 
mm.  in  diameter  which  pass  through  the  prostate  and  vesicule 
seminales. 

Nerves. — The  nerves  of  the  rectum  and  anus  are  derived 
from  both  the  cerebro-spinal  and  sympathetic  systems.  The 
former  are  branches  from  the  sacral  plexus,  the  latter  from  the 
mesenteric  and  hypogastric  plexuses.  The  spinal  nerves  are 
derived  from  the  third  and  fourth  sacral,  which  supply  visceral 
branches  to  all  the  pelvic  organs,  anastomosing  with  branches 


20  DISEASES    OF    THE    RECTUM    AND    ANUS. 

from  the  S37mpathetic.  The  muscular  branches  from  the  same 
nerves  have  already  been  spoken  of  in  connection  with  the  indi- 
vidual muscles.  The  fifth  sacral  nerve  also  sends  a  small  twig 
to  the  coccygeus.  The  posterior  branch  of  the  superficial  peri- 
neal nerve  from  the  internal  pudic  supplies  the  skin  in  front  of 
the  anus,  while  the  anterior  branch  gives  several  small  filaments 
to  the  levator  ani. 

The  inferior  hemorrhoidal  branch  from  the  pudic  supplies 
the  lower  end  of  the  rectum,  the  external  sphincter,  and  the 
skin  of  the  anus.  This  nerve  may  come  direct  from  the  sacral 
plexus  through  the  lesser  sacro-sciatic  notch.  The  posterior 
branches  of  the  sacral  nerves  also  supply  the  skin  over  the 
coccyx  and  around  the  anus. 

According  to  a  brief  contribution  of  W.  Krause,1  the  nerves 
end  in  the  mucous  membrane  of  the  anus,  in  club-shaped  bulbs, 
about  0.05  mm.  in  diameter,  which  lie  under  the  bases  of 
papillae. 

The  tonic  contraction  of  the  external  sphincter  muscle  is,  in 
part  at  least,  due  to  the  influence  of  a  nerve-centre  located  in 
the  lumbar  region  of  the  spinal  cord.2  If  the  nerve  connection 
of  the  sphincter  with  the  spinal  cord  be  severed,  relaxation  of 
the  muscle  takes  place.  The  fact  that  division  of  the  cord  in 
the  dorsal  region  does  not  affect  the  sphincter,  except  tempo- 
rarily by  shock  or  depression,  proves  that  this  centre  is  not 
located  above  the  lumbar  region.  This  nerve-centre  is  subject 
to  various  influences  ;  and  the  sphincter  may  either  be  relaxed, 
or  its  tonic  contraction  increased,  by  local  stimulation,  or  by 
the  influence  of  the  will  or  emotions. 

Though  the  dependence  of  the  sphincter  for  its  tonic  con- 
traction upon  the  lumbar  nerve-centre  seems  so  great,  still  it  is 
not  absolute.  In  the  case  of  a  man  in  whom  the  sacral  nerves 
were  entirely  paralyzed  by  an  injury,  and  in  whom,  therefore, 
there  was  no  nerve  connection  with  the  lumbar  centre  except 
perhaps  through  the  sympathetic,  Gower3  observed  the  main- 
tenance of  a  certain  amount  of  tonic  contraction,  which  could 
be  inhibited  and  relaxation  produced  by  stimulation  of  the 
mucous  membrane  of  the  rectum  and  anus.  From  this  it  would 
appear  that  the  tonic  contraction  of  the  sphincter,  as  is  known 

1  Ksmarch,  op.  cit.,  p.  10. 

2Masius:  Bull,  de  1'Acad.    Royal  de  Belgique,  xxiv.  (1867),  p.  312.      (Foster's 
Physiology,  p.  387.)  3Proc.  Roy.  Soc.  (1877),  p.  77. 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  21 

to  be  the  case  in  the  arterial  system,  is  habitually  dependent  on 
a  spinal  centre,  but  may,  nevertheless,  exist  without  the  action 
of  that  centre.  The  paralysis  of  the  muscle  which  follows  brain 
lesions  is  probably  due  merely  to  inhibition  of  the  spinal  centre, 
and  not  to  the  injury  of  any  centre  located  in  the  cerebrum.1 

The  distribution  of  the  spinal  nerves  serves  to  explain  many 
of  the  reflex  and  so-called  anomalous  symptoms  of  pain  which 
are  encountered  in  diseases  of  the  rectum  and  anus.  Brodie'  re- 
lates an  instructive  case  of  pain  in  the  foot  over  the  distribution 
of  the  sciatic  which  was  cured  by  curing  prolapsing  haemor- 
rhoids— the  irritation  being  primarily  at  the  termination  of  the 
internal  pudic,  and  conveyed  thence  to  the  sacral  plexus,  to  be 
carried  to  the  termination  of  the  great  sciatic.  In  the  same  way 
a  fissure  of  the  anus  or  other  disease  of  the  rectum  may  cause 
pain  in  the  lumbar  and  iliac  regions,  pain,  loss  of  sensation,  and 
cramps  in  the  legs,  and  symptoms  of  bladder  and  urethral  dis- 
ease, besides  more  general  nervous  phenomena.     See  Fig.  6. 

The  chief  nerve-supply  of  the  rectum  is  at  the  lower  portion, 
and  around  the  anus — the  middle  and  upper  portions  possessing 
very  little  sensibility  ;  so  little,  in  fact,  that  the  gravest  diseases, 
such  as  cancer  or  ulceration,  may  exist  and  not  manifest  them- 
selves by  pain.  This  also  explains  how  large  masses  of  faeces 
may  accumulate  in  the  rectal  pouch  without  causing  suffering. 
Puncturing  the  bladder  through  the  rectum  is  not  a  painful 

.  "  Foster's  Physiology,  p.  388.  Philadelphia,  1880. 
2  A  lady  consulted  me,  says  Mr.  Brodie,  concerning  a  pain  to  which  she  had  been 
for  some  time  subject,  beginning  in  the  left  ankle  and  extending  along  the  instep 
toward  the  little  toe,  and  also  into  the  sole  of  the  foot.  The  pain  was  described  as 
being  very  severe.  It  was  unattended  by  swelling  or  redness  of  the  skin,  but  the  foot 
was  tender.  She  labored  also  under  internal  piles,  which  protruded  externally  when 
she  was  at  the  water-closet,  at  the  same  time  that  she  lost  from  them  sometimes  a 
larger  and  sometimes  a  smaller  quantity  of  blood.  On  a  more  particular  inquiry  I 
learned  that  she  was  free  from  pain  in  the  foot  in  the  morning  ;  that  the  pain  attacked 
her  as  soon  as  the  fi  st  evacuation  of  the  bowels  had  occasioned  a  protrusion  of  the 
piles  ;  that  it  was  especially  induced  by  an  evacuation  of  hard  fasces  ;  and  that,  if  she 
passed  a  day  without  any  evacuation  at  all,  the  pain  in  the  foot  never  troubled  her. 
Having  taken  all  these  facts  into  consideration,  I  prescribed  for  her  the  daily  use  of  a 
lavement  of  cold  water  ;  that  she  should  take  the  Ward's  paste  (confectio  piperis  com- 
posita)  three  times  daily,  and  some  lenitive  electuary  at  bedtime.  After  having  per- 
severed in  this  plan  for  a  space  of  six  weeks,  she  called  on  me  again.  The  piles  had 
now  ceased  to  bleed,  nnd  in  otber  respects  gave  her  scarcely  any  inconvenience.  The 
pain  in  the  foot  had  entirely  left  her.  She  observed  that,  in  proportion  as  the  symp- 
toms produced  by  the  piles  had  abated,  the  pain  in  the  foot  had  abated  also. — Medical 
Gazette,  vol.  v. 


99 


DISEASES    OF    THE    KECTUM    AND    ANUS. 


operation,  and  applications  of  strong  acids  to  the  mucous  mem- 
brane will  cause  little  suffering  if  the  skin  be  properly  protected. 
Exactly  the  opposite  condition  obtains  at  the  anus,  the  extreme 
sensibility  of  which  is  well  known. 

The  pelvic  plexuses  of  the  sympathetic  are  placed  one  on 
either  side  of  the  rectum  and  vagina.  Each  is  composed  of  pro- 
longations from  the  hypogastric  plexus  above,  united  with 
branches  from  the  sacral  ganglia.  The  spinal  branches  to  the 
sj^mpathetic  are  mostly  from  the  third  and  fourth  sacral  nerves. 
From  the  back  part  of  the  plexus  thus  formed  are  given  off  the 
inferior  hemorrhoidal  nerves,  which  join  with  the  superior 
hemorrhoidal  from  the  inferior  mesenteric  artery  and  perforate 
the  rectal  wall. 


Fig.  C. — Diagrammatic  View  of  the  Nerves  of  the  Anus.  (Hilton.)  a,  Ulcer  on  sphincter  ; 
b,  the  filaments  of  two  nerves  are  exposed  on  the  ulcer,  the  one  a  sensory  and  the  other  motor, 
both  attached  to  the  spinal  marrow,  thus  constituting  an  excito-motory  apparatus  ;  c,  levator 
ani ;  c7,  transversus  perinei. 


Lymphatics. — The  lymphatic  vessels  of  the  rectum  are 
arranged  like  those  of  the  intestine  generally,  in  two  layers ; 
one  beneath  the  peritoneum  and  one  between  the  mucous  and 
muscular  coats.  Immediately  after  leaving  the  bowel  some  of 
the  vessels  pass  through  small  adjacent  glands,  and  all  finally 
enter  the  glands  in  the  hollow  of  the  sacrum,  or  those  higher  up 
in  the  loin. 

But  just  as  there  is  an  internal  and  external  system  of  veins, 
one  proper  to  the  rectum,  the  other  to  the  anus,  so  is  there  an- 
other  lymphatic  system,  which  conies  from  the  integument 
around  the  anus  and  passes  to  the  glands  in  the  groin ;  and 
these  two  sets  of  vessels  freely  communicate  with  each  other. 
A  knowledge  of  this  fact  is  of  importance  in  the  diagnosis  of 
cancer  of  the  rectum  ;  and  the  glands  which  are  deep  in  the  pel- 


POINTS   IN    ANATOMY   AND    PHYSIOLOGY.  £3 

vis  along  the  sacrum  should  always  be  felt  for,  as  well  as  those 
located  in  the  groin. 

Defecation. — A  study  of  the  anatomy  of  the  rectum  would 
not  be  complete  without  some  reference  to  its  physiological 
functions.  We  shall,  therefore,  in  this  place  consider  the  func- 
tion of  defecation,  postponing  the  question  of  absorption  until 
we  consider  that  of  rectal  alimentation. 

In  regard  to  defecation  the  question  at  once  arises,  how,  after 
destruction  of  the  lower  end  of  the  rectum,  or  paralysis  of  the 
sphincters,  there  still  remains  a  certain  amount  of  control  over 
the  evacuations  %  Such  an  injury  is  often  only  noticeable  through 
a  constant  discharge  of  rectal  mucus,  and  an  occasional  involun- 
tary escape  of  fluid  fseces  when  the  patient  is  suffering  from 
diarrhoea.  This  leads  naturally  to  a  consideration  of  the  third 
or  superior  sphincter  muscle,1  whose  existence  has  been  sup- 
posed to  account  for  such  control  of  the  evacuations  as  exists 
in  this  condition. 

It  is  now  about  half  a  century  since  Nelaton  first  described 
the  third  sphincter  muscle,  and,  in  spite  of  all  that  has  been 
written  concerning  it  since  that  time,  it  is  only  a  few  years  since 
Van  Buren2  characterized  it  as  an  organ  to  which  anatomy  and 
physiology  had  been  equally  unsuccessful  in  assigning  either 
certainty  of  location  or  certainty  of  function.  For  the  original 
description  of  the  muscle  by  Nelaton  we  are  indebted  to  Vel- 
peau,  who  writes  that  he  has  verified  the  existence  of  a  sort  of 
sphincter  of  the  rectum,  lately  discovered  by  Nelaton,  and  goes 
on  to  say  that  it  is  a  muscular  ring  situated  about  four  inches 

1  Gosselin  :  "  Retrecissements  Syphilitiques  du  Rectum:"  Arch.  Genl.  du  Med., 
1854,  p.  668. 

Henle  :  "  Handb.  der  systemat.  Anat.  des  Menschen,"  1873,  Bd.  ii. 

Hyrtl :  "  Handb.  der  topogr.  Anat.,"  Wien,  1857,  Bd.  ii.,  pp.  108,  109. 

Sappey  :  "  Traite  dAnat.  Descriptive,"  Paris,  1874,  t.  iv. 

Chad  wick  :  "  Trans,  of  the  Am.  Gynaecol.  Soc,"  ii.,  1877. 

Petrequin:  "Traite  d'Anat.  Topogr.  Med.-Chirurg.,"  etc.,  2me  ed.,  Paris,  1857, 
p.  414. 

Houston:   "Dublin  Hosp.  R,"  v.,  1830. 

O'Beirne  :   "  New  Views  of  the  Process  of  Defecation,"  etc.,  Dublin,  1833. 

Bushe :  "Treatise  on  the  Malformations,  Injuries,  and  Diseases  of  the  Rectum 
and  Anus,"  New  York,  1837. 

Kohlrausch :    "Anat.  u.  Physiol,  der  Beckenorgane,"  Leipzig,  1854. 

Rosswinkler  :  "Wien.  med.  Woch.,"  1852,  p.  435. 

Foster  :   "  Text-Book  of  Physiology,"  Philadelphia,  1880,  p.  387. 

2  "On  Phantom  Stricture,"  etc.  :  Am.  Jour,  of  the  Med.  Sci.,  October,  1879. 


24  DISEASES    OF    THE    RECTUM    AND    ANUS. 

above  the  anus,  just  in  the  place  where  retractions  of  the  rec- 
tum are  most  often  found.  If,  after  turning  the  rectum  so  that 
its  mucous  surface  is  external,  it  is  moderately  distended  Ijv 
insufflation,  the  muscle  will  be  seen  to  be  made  up  of  fibres 
collected  into  bundles.  Its  breadth  is  from  six  to  seven  lines  in 
front,  and  about  an  inch  behind.  Its  thickness,  on  the  contrary, 
is  much  greater  in  front,  where  the  fibres  appear  to  be  collected 
in  the  angle  which  corresponds  to  the  union  of  the  first  and 
second  curves,  of  the  rectum,  while  behind  they  are  scattered 
over  its  convexity.  After  thus  adopting  the  description  of  ~Ne- 
laton,  Velpeau ]  brings  out  one  other  anatomical  point — the 
attachment  of  the  muscle  posteriorly  to  the  front  of  the  sacrum. 
The  functions  ascribed  to  the  muscle  by  Nelaton  were  those  of 
keeping  the  rectum  empty  until  a  short  time  before  the  act  of 
defecation  ;  separating  the  fsecal  mass  and  preventing  its  regur- 
gitation during  defecation  :  and  of  opposing  the  continuous  and 
involuntary  escape  of  faeces  after  the  destruction  of  the  lower 
sphincters. 

Hyrtl  refers  to  this  description,  and  himself  describes  the 
muscle  as  being  six  or  seven  lines  in  breadth  anteriorly  and  an 
inch  posteriorly,  but  does  not  always  find  it  present.  He  also 
in  one  case  demonstrated  the  attachment  to  the  sacrum.  Sap- 
pey  admits  its  frequent  existence,  and  locates  it  at  the  level  of 
the  base  of  the  prostate,  in  the  middle  portion  of  the  rectum, 
six,  seven,  eight,  or  sometimes  nine  centimetres  from  the  anus. 
It  never  completely  surrounds  the  rectum,  but  only  one-half  or 
two-thirds  of  its  circumference  ;  and  it  appears  to  him  to  be 
caused  by  a  grouping  of  the  circular  muscular  fibres,  some 
being  gathered  from  below  upward,  and  others  from  above 
downward,  to  the  same  point.  Its  breadth  is  one  centimetre 
and  its  thickness  two  or  three  millimetres.  Situated  sometimes 
in  front,  sometimes  behind,  and  again  laterally  or  anterolater- 
al ly,  it  is  constant  in  nothing  except  its  direction  perpendicular 
to  the  axis  of  the  bowel.  In  place  of  one,  he  has  sometimes 
found  two  bands  at  opposite  points  and  different  levels,  and  in 
one  specimen  which  he  has  preserved  there  were  three.  Henle 
adopts  Sappey's  description  in  the  main.  Petrequin  found  the 
muscle  irregularly  oblique,  less  marked  in  the  front  wall  than 
in  the  back,  and   consisting  of  a  collection  of  weak  bands  of 


Velpeau:   "  Traitu  d'Anat.  Chirurg.,"  3me  ed.,  1837,  Introduction,  p.  39. 


POINTS    IN"    ANATOMY    AND    PHYSIOLOGY.  25 

fibres.  Cliadwick  asserts  that  no  distinct  muscle  exists,  but 
describes  in  place  of  it  two  agglomerations  of  the  circular  mus- 
cular fibres,  one  on  the  anterior  and  one  on  the  posterior  wall, 
corresponding  to  two  semicircular  constrictions,  which  may  be 
felt  by  digital  examination,  and  whose  effect  is  to  give  the  rec- 
tum its  sigmoid  curve. 

The  third  sphincter  muscle  and  the  valves  of  mucous  mem- 
brane in  the  rectum  are  not,  as  might  be  supposed,  one  and  the 
same  thing,  though  it  is  true  that  they  have  become  almost 
hopelessly  confounded  in  surgical  and  anatomical  literature, 
and  are  often  spoken  of  as  identical.  As  far  as  possible,  we 
shall  try  to  consider  them  separately,  without  doing  violence  to 
the  text  of  the  authorities.  The  valves  of  the  rectum  (we  nse 
the  word  simply  as  expressing  the  folds  of  mucous  membrane) 
were  first  described  by  Houston  at  about  the  same  time  that 
Nelaton  described  the  superior  sphincter ;  and  it  is  worth  re- 
membering that  the  two  authors  were  writing  about  two  entirely 
different  tilings,  and  two  things  which  stood  in  no  necessary  re- 
lation to  each  other,  so  far  as  wre  may  judge  from  their  descrip- 
tions. Houston's  method  of  preparation  was  by  filling  and  dis- 
tending the  gut  with  spirit  before  its  removal  from  the  body, 
and  then  laying  it  open  longitudinally.  He  states  that  the 
folds  disappear  if  the  bowel  is  first  removed  from  its  natural 
position  and  then  distended,  but  that  they  may  be  seen  in  the 
natural  condition  of  the  parts  soon  after  death,  before  the  tonic 
contraction  has  disappeared  ;  and  that  they  are  then  found  to 
overlap  each  other  so  effectually  as  to  require  considerable 
manoeuvring  in  order  to  pass  a  bougie  or  the  finger  along  the 
bowel.  It  is  also  remarked  that  this  is  just  the  arrangement 
necessary  to  prevent  the  faeces  from  urging  their  way  toward 
the  anus,  where  their  presence  would  excite  a  constant  sensa- 
tion demanding  their  discharge. 

According  to  this  first  and  clearest  of  all  the  descriptions — for 
the  whole  article  is  written  with  a  force  and  clearness  of  style 
which  have  perhaps  had  an  undue  weight  in  disarming  criticism 
as  to  the  facts — the  valves  exist  in  all  persons,  but  vary  much 
in  different  individuals  as  to  location  and  number.  Three  is 
the  average  number,  though  sometimes  four,  and  again  only 
two  are  well  marked.  The  largest  and  most  constant  is  about 
three  inches  from  the  anus,  opposite  the  base  of  the  bladder  ; 
the  next  most  constant  is  at  the  upper  end  of  the  rectum  ;  the 


26        •  DISEASES    OF    THE    RECTUM    AND    ANUS. 

third  is  about  midway  between  these  ;  and  the  fourth,  or  the 
one  most  rarely  present,  is  attached  to  the  side  of  the  gut  about 
an  inch  above  the  anus.  The  first  one  generally  projects  from 
the  right  wall  ;  the  one  next  above  from  the  left  ;  the  upper- 
most from  the  right  ;  and  the  one  nearest  the  anus,  when  pres- 
ent, from  the  left  and  posterior  wall  ;  the  arrangement  being 
such,  in  spite  of  variations,  as  to  form  a  spiral  tract  down  the 
gut.  The  folds  are  described  as  semilunar  in  form,  with  the 
convex  border  attached  to  the  side  of  the  bowel,  and  occupying 
from  one-third  to  one-half  of  its  circumference.  The  surfaces  are 
sometimes  horizontal,  but  more  often  oblique,  with  the  sharp, 
concave,  floating  margin  generally  directed  a  little  upward.  In 
breadth  they  vary  from  one-half  to  three-quarters  of  an  inch  or 
more  in  the  distended  state  of  the  gut  ;  and  they  are  said  to  be 
composed  of  a  duplicature  of  mucous  membrane  inclosing  some 
cellular  tissue  and  a  few  of  the  circular  muscular  fibres. 

The  palpable  weak  points  in  Houston's  article  were  very 
soon  pointed  out  by  O'Beirne,  in  a  work  of  marked  and  almost 
amusing  originality.  The  views  were  indeed  "new,"  but  they 
are  to-day  accepted  in  many  points  by  those  whose  judgment  is 
worthy  of  the  most  confidence  in  these  matters.  O'Beirne  seems 
rather  to  regret  that  he  is  unable  to  accept  Houston's  statements 
as  to  an  anatomical  condition  which  would  account  so  fully  and 
so  easily  for  the  physiological  emptiness  of  the  rectum  and  ful- 
ness of  the  sigmoid  flexure  on  which  his  own  views  depend  ;  but 
nevertheless  he  sets  himself  to  the  task  of  demolishing  them 
with  great  vigor  and  considerable  success.  Although  he  believes 
the  rectum  to  be  normally  empty,  except  just  at  the  time  of 
defecation,  he  believes  that  condition  to  depend  upon  the  ana- 
tomical arrangement  of  the  sigmoid  flexure,  joined  with  the  nar- 
rowing of  the  upper  end  of  the  rectum,  which  is  entirely  inde- 
pendent of  any  folds  of  mucous  membrane.  He  not  only  denies 
the  existence  of  any  such  folds,  but  states  flatly  that  Houston 
is  altogether  incorrect  in  his  statement  that  Cloquet  or  any  other 
anatomist  before  his  time  makes  even  the  slightest  allusion  to 
them.'     He  believes  the  folds  to  have  been  produced  by  the 

1  Regarding  this  question  of  fact,  it  may  be  well  to  quote  Cloquet's  description 
from  Bu«he,  op.  cit.,  p.  GO  :  "The  inner  surface  of  the  rectum  is  commonly  smooth 
in  its  upper  half,  but  in  the  lower  there  are  observed  some  parallel  longitudinal  wrin- 
kles, wbich  are  thicker  near  the  anus,  and  are  variable  in  length.  These  wrinkles, 
whose  number  varies  from  four  to  ten  or  twelve,  and  which  are  called  the  columns  of 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY  27 

method  of  making  the  preparations — distending  and  hardening 
all  the  parts  with  spirit  before  making  the  incision — and  asserts 
that  this  method  is  anything  but  natural,  and  nothing  more  or 
less  than  an  attempt  to  exhibit  natural  appearances  by  placing 
the  parts  in  an  unnatural  situation — such  a  situation,  indeed, 
as  is  not  known  to  be  necessary  for  the  exhibition  of  the  valvu- 
lar conniventes  or  any  other  valves  of  the  body.  He  meets  the 
statement,  that  by  the  ordinary  procedure  of  distending  the  rec- 
tum after  removal  from  the  body  the  valves  are  made  to  disap- 
pear, by  the  question,  why,  if  such  valves  really  exist,  and  if 
muscular  fibres  enter  into  their  structure,  they  should  not  be 
discoverable  at  any  time  after  death,  or  in  any  state  of  the  in- 
testine— a  question  very  difficult  of  solution. 

Four  years  later  the  voice  of  a  New  York  surgeon  is  raised 
against  these  folds,  and  in  almost  the  same  language  as 
O'Beirne's,  though  from  an  entirely  independent  standpoint. 
Bushe  declares  that  he  has  never,  in  the  living  body,  been  able 
to  detect  any  valve  of  such  firmness,  and  capable  of  exerting 
any  such  influence  upon  the  descent  of  the  faeces  as  Houston 
describes,  though  he  has  frequently  met  with  accidental  folds 
produced  by  the  partial  contraction  of  the  bowel ;  and  the  proof 
that  they  are  accidental  is  that,  in  the  same  subject,  he  has  on 
different  days  found  them  to  occupy  different  situations,  but 
always  they  were  unresisting  and  easily  displaced  by  the  ex- 
tremity of  the  finger.  He  points  out  that,  by  the  method  of 
hardening  the  rectum  after  distending  it  with  spirit,  these  acci- 
dental folds  are  rendered  permanent  by  the  induration  resulting 
from  the  action  of  the  alcohol ;  and  that,  by  the  method  of  in- 
flation and  drying,  the  projections  resembling  valves  are  pro- 
duced by  the  angles  formed  by  the  setting  of  the  intestine  dur- 
ing the  process  of  desiccation. 

Kohlrausch  describes  and  figures  one  important  fold,  the 
plica  transversalis  recti,  which  he  locates  at  the  same  point  as 
Houston's  most  constant  one,  projecting  well  into  the  lumen  of 
the  bowel  from  the  right  side.     It  forms  rather  more  than  a 


the  rectum,  are  formed  by  the  mucous  membrane  and  the  layer  of  the  subjacent  cellu- 
lar tissue.  Between  these  columns  there  are  almost  always  to  be  found  membranous 
semilunar  folds,  more  or  less  numerous,  oblique  or  transverse,  of  which  the  floating' 
edge  is  directed  from  below  upward  toward  the  cavity  of  the  intestine.  These  folds 
form  a  kind  of  lacunae,  of  which  the  bottom  is  narrow  and  directed  downward."  It 
seems  evident  that  the  sinuses  of  Morgagni  are  here  referred  to. 


28  DISEASES    OF    THE    KECTUM    AND    ANUS. 

semicircle,  and  runs  further  on  the  anterior  than  on  the  poste- 
rior wall.  Here  also  we  meet  the  direct  statement  that  this  fold 
is  now  known  as  the  sphincter  ani  tertius,  though  Kohlrausch 
does  not  consider  such  a  title  justified  by  the  anatomical  condi- 
tion, inasmuch  as  the  circular  muscular  fibres  do  not  enter  into 
its  texture,  and  are  not  more  developed  here  than  elsewhere. 
For,  though  both  these  things  may  happen,  as  a  rule  neither  is 
the  case. 

Sappey  says  he  has  found  in  the  empty  state  various  folds 
of  the  mucous  membrane,  but  that  these  have  no  determinate 
direction,  and  are  generally  only  slightly  marked.  Three  times 
onty,  in  thirty  recta  which  he  examined,  has  he  met  with  any- 
thing which  at  all  answered  to  Kohlrausch' s  plica  transversalis, 
or  to  Houston's  chief  valve.  There  is  nothing  to  prove  that 
they  persist  when  the  rectum  is  full  ;  on  the  contrary,  it  is 
probable  that  they  are  effaced  by  the  simple  fact  of  distention 
of  the  latter,  at  least  in  great  part.  The  name  of  valve  is 
not,  therefore,  applicable  to  them,  and,  admitting  even  that  it 
might  be  used  by  one  of  those  abuses  of  language  so  frequent  in 
anatomy,  Houston  would  still  incur  the  discredit  of  having  pre- 
sented as  normal  a  fact  which  is  only  observed  very  exception- 
ally. 

Henle  divides  the  valves  into  two  varieties,  the  temporary 
and  the  permanent.  Of  the  former  he  describes  several,  which 
may  be  present  or  absent  in  the  same  individual  at  different 
times  or  in  different  states  of  the  bowel.  Of  the  permanent 
variety  there  is  only  one — the  plica  transversalis — and  this  one 
is  only  present  in  a  minority  of  subjects. 

Hyrtl  describes  two  folds,  both  constant :  one  on  the  right 
wall  lower  down,  and  one  on  the  opposite  side.  Rosswinkler 
also  describes  two  folds,  but  locates  them  on  opposite  sides  to 
those  of  Hyrtl. 

There  would  be  but  little  profit  in  following  these  descriptions 
of  different  writers,  each  of  them  an  autliorit}^  on  the  subject 
treated,  any  further  ; '  and  so  far  as  we  have  gone,  we  have 
carefully  endeavored  to  avoid  any  violence  to  the  meaning  of 
the  text  in  thus  separating  the  thickening  of  the  muscular 

1  Morgagni  ("  De  Sedibus  et  Causis  Morborum  ")  says  he  found  valves  in  two  sub- 
jects, situated  about  an  inch  above  the  anus,  in  one  of  a  circular,  in  the  other  of  a 
crucial  form.  The  references  of  Portal  ("  Anat.  Med."),  Glisson,  and  Boyer  ("  Traito 
dAnat,,''  Paris,  1815,  .t.  iv.,  p.  377)  probably  all  refer  to  the  sinuses  of  Morgagni. 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  29 

fibres,  which  can  alone  constitnte  a  sphincter,  from  the  projec- 
tions and  redundancies  of  the  mucous  membrane  which  Houston 
first  described  under  the  name  of  valves.  It  will  readily  be  seen 
that  Van  Buren  was  correct  in  speaking  of  the  third  sphincter 
as  an  organ  to  which  anatomy  and  physiology  had  been  equally 
unsuccessful  in  assigning  certainty  of  location,  for  we  have  seen  it 
described,  on  equally  good  authority,  as  both  mucous  membrane 
and  muscle  ;  as  on  all  sides  of  the  rectum,  and  at  almost  all  dis- 
tances between  two  and  four  inches  from  the  anus ;  as  single, 
double,  and  triple  ;  as  composed  of  mucous  membrane  and  cel- 
lular tissue  without  muscular  fibre,  and  of  well-marked  mus- 
cular bands  located  at  the  base  of  the  mucous  folds,  and  extend- 
ing into  their  substance.  From  these  very  differences,  perhaps, 
the  true  anatomy  of  the  part  may  best  be  deduced.  It  is  the 
old  question  of  the  gold  and  silver  shield.  There  are  bands  of 
the  circular  muscular  fibres  of  the  rectum  located  at  various 
points  in  its  upper  portion.  These  bands  are  more  or  less  de- 
veloped in  different  subjects,  and  are  also  found  in  no  constant 
location  ;  being  sometimes  lower  or  higher,  and  sometimes  more 
marked  on  the  anterior  or  again  on  the  posterior  wall.  There 
are  also  found  various  folds  and  duplicatures  of  the  mucous 
membrane,  which  stand  in  no  constant  relation  to  the  thickened 
portions  of  the  muscular  fibre,  and  have  no  definite  or  constant 
situation,  but  may  alter  their  shape  with  the  varying  condition 
of  the  bowel,  and  are  found  at  different  points  in  different  sub- 
jects. These  folds  vary  also  in  their  structure  in  different  peo- 
ple, being  larger  and  firmer  in  some  than  in  others,  and  occa- 
sionally containing  a  few  fibres  of  the  circular  muscle  of  the 
bowel. 

This  is  also  the  conclusion  reached  by  Gosselin,  who  says  : 
"  I  do  not  find  the  line  of  demarcation  (between  the  upper  and 
middle  portions  of  the  rectum)  established  by  a  special  sphincter 
analogous  to  that  which  some  authors  have  indicated  by  the  name 
of  sphincter  superior.  lam  convinced, indeed,  by  the  examina- 
tion of  a  large  number  of  specimens  that  the  sphincter  does  not 
exist  as  an  isolated  muscle,  and  that,  when  we  are  led  to  admit  its 
existence,,  we  have  to  do  with  subjects  in  whom  the  bands  of  the 
circular  layer  are  more  developed  than  in  others.  I  have  often 
met  this  isolated  development  of  some  of  the  circular  fibres,  but 
it  is  by  no  means  always  present,  and  for  this  reason  the  superior 
sphincter  has  not  always  been  found  by  those  who  have  searched 


30  DISEASES    OF    THE    RECTUM    AND    ANUS. 

for  it.  When  it  exists  it  is  at  a  variable  height,  sometimes  be- 
tween the  middle  and  upper  portions,  sometimes  at  some  part 
of  the  circumference  of  the  latter,  or  at  its  very  upper  portion  ; 
and  I  explain  in  this  way  why  O'Beirne  has  placed  his  superior 
sphincter  at  the  junction  of  the  rectum  with  the  sigmoid  flexure, 
while  Nelaton  has  placed  his  lower  down,  without  assigning  it 
a  determinate  position." 

It  will  be  remembered  that  Hyrtl  argued  backward  from 
what  he  considered  the  physiology  of  the  rectum  to  the  exist- 
ence of  a  third  sphincter ;  and  that  Houston,  in  describing  the 
valves  of  membrane,  asserts  that  such  an  arrangement  as  he  dis- 
covered was  just  the  one  which  was  a  posteriori  probable,  and 
which  best  accounted  for  the  accepted  theories  of  the  physiology 
of  defecation.  Kelaton,  too,  though  he  described  the  muscle  be- 
fore he  gave  it  an  action,  assigns  to  it  the  same  function  as  Hous- 
ton does  to  his  folds,  and  as  Hyrtl  believed  it  must  of  necessity 
possess.  It  is  plain  that  each  was  led  by  a  certain  chain  of  rea- 
soning to  believe  in  the  existence  of  an  obstruction  to  the  passage 
of  faeces  from  the  sigmoid  flexure  above  to  the  rectum  below ; 
and  that  two  of  them  found  it  in  the  muscular  structure,  and 
the  third  in  the  mucous  membrane  of  the  bowel.  The  facts  upon 
which  the  necessity  for  a  superior  sphincter  are  supposed  to  rest 
are  briefly  these :  the  normally  empty  state  of  the  rectum,  and 
the  ability  to  retain  both  wind  and  motion  after  destruction  of 
the  anus  and  its  muscles.  The  force  of  this  line  of  argument 
cannot  be  disputed,  but  were  some  other  reasonable  explanation 
found  for  these  two  facts  than  the  existence  of  a  third  muscle, 
that  muscle  would  soon  be  dropped  from  the  descriptions  of  the 
anatomy  of  this  part.  The  whole  tendency  of  the  physiology 
of  the  day  is  to  furnish  such  an  explanation. 

The  "  new  views  "  of  O'Beirne  with  regard  to  the  process  of 
defecation  were  simply  as  follows  :  The  repeated  descent  of  fsecal 
masses  causes  the  sigmoid  flexure  to  become  distended,  and  to 
ascend  from  its  position  in  the  cavity  of  the  true  pelvis  into  the 
left  iliac  fossa.  When  this  occurs  the  flexure,  in  proportion  to 
the  rapidity  and  degree  of  its  distention,  begins  to  turn  upon  the 
contracted  rectum  as  upon  a  fixed  point,  until  at  length,  like  the 
Stomach,  it  directs  its  greater  arch  forward  and  upward,  and  its 
lesser  backward  and  downward.  By  this  movement  the  con- 
tents are  brought  somewhat  perpendicular  to,  and  so  as  to  press 
directly  upon  the  upper  extremity  of  the  contracted  rectum. 


POINTS    IN    ANAT03IY    AND    PHYSIOLOGY.  31 

But  as  the  mere  weight  is  insufficient  to  force  a  passage  down- 
ward, and  as  this  end  cannot  be  accomplished  either  by  such 
gentle  pressure  as  that  exerted  by  the  alternate  contraction  of 
the  diaphragm  and  the  abdominal  muscles  in  ordinary  respira- 
tion, or  by  the  efforts  of  the  flexure  itself,  in  consequence  of  its 
muscular  power  being  so  inferior  to  that  of  the  rectum,  the 
faeces  are  compelled  to  remain  stationary  until  such  time  as  the 
increased  accumulation  and  distention  produce  a  sense  of  un- 
easiness sufficient  to  call  into  action  those  great  expulsive 
agents,  the  diaphragm  and  abdominal  muscles.  These  muscles, 
instead  of  acting  alternately,  now  act  simultaneously,  compress 
the  abdomen  and  its  contents  on  all  sides,  urge  the  free  and 
floating  mass  of  small  intestine  downward  and  even  into  the 
cavity  of  the  pelvis,  so  as  to  press  forcibly  not  only  upon  the 
sigmoid  flexure,  but  also  upon  the  caecum  and  urinary  bladder. 
By  these  means  the  contents  of  the  distended  flexure  are  acted 
upon  in  every  direction,  and  so  as  to  be  impelled  against  the 
upper  annulus  of  the  contracted  rectum  with  a  force  sufficient  to 
compel  its  parietes  to  separate  and  afford  a  passage.  The  nisus 
now  ceases,  but  as  soon  as  the  rectum  becomes  filled,  it  is  aroused 
to  make  an  expulsive  effort  by  which  its  contents  are  driven  or 
impacted  into  its  pouch.  Here  they  produce  a  great  sense  of 
weight  and  uneasiness  in  the  perineum,  an  urgent  desire  to  go 
to  stool,  and  a  still  stronger  nisus,  by  which  the  sphincters  are 
forced  open  and  dilated,  and  the  final  expulsion  of  the  faeces  is 
effected.  This  reasoning,  it  will  be  seen,  is  entirely  based  upon 
the  normal  empty  and  contracted  state  of  the  rectum,  which 
O'Beirne  not  only  states  to  be  a  clinical  fact  capable  of  easy 
demonstration,  but  gives  many  reasons  for,  the  chief  being  the 
great  relative  thickness  of  its  muscular  wall.  He  clearly  pointed 
out  also  (what  has  been  frequently  verified  since,  and  especially 
by  those  who  have  passed  the  hand  into  the  sigmoid  fiexure  of 
the  living  subject)  that  the  upper  extremity  of  the  rectum  was 
absolutely  the  smallest  part  of  this  portion  of  the  bowel ;  but 
that  nothing  of  the  nature  of  a  sphincter  muscle,  located  at  this 
point  or  near  it,  entered  into  his  calculation  any  more  than  did 
the  folds  of  mucous  membrane. 

Compare,  now,  these  teachings  of  O'Beirne's,  in  1833,  which 
we  have  already  said  are  to-day  accepted  by  those  who  have 
the  best  right  to  judge  of  these  matters,  with  those  of  Foster,  in 
1880.     He  says  the  faeces,  in  their  passage  through  the  colon, 


62  DISEASES    OF    THE    RECTUM    AND    ANUS. 

are  lodged  in  the  sacculi  during  the  pauses  between  the  peris- 
taltic waves.  Arrived  at  the  sigmoid  flexure,  they  are  supported 
by  the  bladder  and  the  sacrum,  so  that  they  do  not  press  on  the 
sphincter  ani.  Defecation  is  a  composite  act,  being  superficially 
the  result  of  an  effort  of  the  will,  and  yet  carried  out  by  means 
of  an  involuntary  mechanism.  The  voluntary  effort  is  composed 
of  two  factors — a  pressure  effect  produced  by  the  contraction  of 
the  abdominal  muscles,  and  a  relaxation  of  the  sphincter  ani 
muscle.  By  the  pressure  of  the  abdominal  muscles  the  contents 
of  the  descending  colon  are  driven  onward  into  the  rectum,  but 
the  sigmoid  flexure  itself  is  shielded  by  its  situation  from  the 
direct  force  of  this  pressure,  and  a  body  introduced  per  anum 
into  the  empty  rectum  is  not  affected  by  even  forcible  contrac- 
tion of  the  abdominal  muscles.  The  sphincter  muscle  guarding 
the  anus  is  habitually  in  a  state  of  tonic  contraction,  capable  of 
being  increased  or  diminished  by  a  stimulus  applied  either  in- 
ternally or  externally  to  the  anus.  This  tonic  contraction  is 
due,  in  part  at  least,  to  the  action  of  a  nervous  centre  situated 
in  the  lumbar  portion-  of  the  spinal  cord.  By  the  action  of  the 
will,  by  emotions,  or  by  other  nervous  events,  the  lumbar 
sphincter  centre  may  be  inhibited,  and  thus  the  sphincter  itself 
relaxed  ;  or  stimulated,  and  thus  the  sphincter  tightened.  This 
relaxation  is  the  second  of  the  voluntary  elements  in  the  act  of 
defecation.  By  these  two  alone  the  contents  of  the  descending 
colon  might  be  pressed  onward  into  the  rectum  and  out  at  the 
anus  ;  but  since  the  sigmoid  flexure  itself  is  subject  to  neither 
of  these  influences,  such  a  mode  of  defecation  would  always  end 
in  leaving  it  full ;  and  therefore  there  is  superadded  to  these 
two  voluntary  elements  an  entirely  involuntary  increase  in  the 
peristaltic  action  of  the  sigmoid  flexure  itself.  The  order  of 
events  is  the  reverse  of  what  we  have  stated.  The  sigmoid  flex- 
ure and  large  intestine  become  more  and  more  full,  while  stronger 
and  stronger  peristalsis  is  excited  in  their  walls.  By  this  means 
the  faeces  are  driven  against  the  sphincter.  Through  a  voluntary 
act,  or  sometimes  at  least  by  a  simple  reflex  action,  the  lumbar 
centre  is  inhibited  and  the  sphincter  relaxed.  At  the  same 
moment  the  contraction  of  the  abdominal  muscles  causes  firm 
pressure  on  the  descending  colon,  and  the  contents  of  the  rec- 
tum are  ejected. 

It  should  be  mentioned  that  the  one  fact  on  which  these 
physiological  views  rest,  viz.,  the  normal  empty  state  of  the 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  33 

rectum,  is  not  universally  admitted.  Indeed,  as  Hyrtl  says, 
the  rectum  will  be  found  by  any  one  who  practises  frequent 
digital  examination,  in  very  different  states  in  this  regard  at 
different  times  in  the  same  individual.  This  may  or  may  not 
be  entirely  due  to  changes  produced  by  constipation  in  those 
examined  ;  but  even  he  admits  that  it  is  more  often  found  empty 
than  any  other  part  of  the  canal ;  and  ,the  difficulty  which  an 
opposite  view  leads  to  will  be  seen  at  once  by  the  attempt  of 
Bushe  to  explain  the  act  of  defecation,  starting  from  the  point 
that  the  faeces  accumulate  slowly  in  the  rectum,  and  gradually 
lose  their  thinner  parts  by  absorption  while  there.  He  goes  on 
to  say  that  they  give  rise  to  no  uneasiness  until  a  considerable 
quantity  is  amassed,  when  a  sensation  is  created  which  demands 
their  expulsion.  This  sensation  is,  he  believes,  not  due  to  the 
mere  contact  of  fsecal  matter,  for  the  latter  generally  accumu- 
lates in  large  quantities  before  the  sensation  is  felt.  Nor  is  it 
due  to  any  peculiar  acrimony  which  they  obtain  by  their  stay 
in  the  rectum,  for  wlien  the  fseces  are  fluid,  this  sensation  is 
produced  as  soon  as  they  reach  the  rectum.  Again,  when  once 
the  sensation  is  felt  and  not  attended  to  it  passes  away,  and 
does  not  return  till  the  next  accustomed  period  ;  and  the  longer 
it  is  unattended  to  the  less  likely  is  it  to  return  at  all.  In  truth, 
he  says,  we  are  ignorant  of  the  cause  of  this  feeling,  and  must,  in 
the  present  state  of  our  knowledge,  admit  that  it  is  organic,  and 
consequently  dependent  upon  some  spontaneous  change  in  the 
intestine,  of  which  we  know  nothing.  Rather  a  lame  conclusion  ! 
Nor  is  the  cause  of  this  periodically  recurring  desire  to  evacuate 
the  bowel  touched  upon  in  the  exposition  given  by  O'Beirne  ; 
and  this  is  the  weak  point  in  his  argument,  and  the  one  which 
renders  Foster's  explanation  complete. 

We  need  cite  authorities  no  further  to  show  that  physiology 
no  longer  teaches  the  existence  of  an  ever-present  mass  of  fseces 
in  the  lower  bowel,  ready  to  escape  at  any  moment  when  the  ac- 
tive watchfulness  of  the  sphincter  muscle  is  relaxed,  or  to  prove 
that  into  our  present  understanding  of  the  cause  of  the  empti- 
ness of  the  rectum  a  third  sphincter  muscle  does  not  enter  as  a  ne- 
cessary element,  but  that  the  true  explanation  of  the  condition 
lies  in  the  anatomy  of  the  sigmoid  flexure,  which,  by  its  large 
size,  great  capability  of  expansion,  loose  mesenteric  attachment, 
and  position,  is  peculiarly  fitted  to  act  the  part  of  a  reservoir. 

Nor  does  the  phenomenon  of  retention  of  fseces  after  the  de- 

3 


34  DISEASES    OF    THE    TECTUM    AND    ANUS. 

struction  of  the  anus  and  its  muscles  necessitate  the  belief  in 
a  superior  sphincter.  So  far  as  our  reading  goes,  no  one  has  as 
yet  attempted  to  prove  the  existence  of  a  fourth  sphincter  in 
the  ascending  colon  ;  and  yet  the  same  control  over  the  pas- 
sages which  has  been  noticed  after  extirpation  of  the  anus,  and 
has  been  supposed  to  indicate  a  third  sphincter,  has  been  ob- 
served to  follow  an  artificial  anus  in  the  transverse  colon.1 

There  are  several  ways  of  accounting  for  the  slight  control 
over  the  evacuations  which  many  patients  are  found  to  have 
after  extirpation  of  the  anus,  apart  from  the  existence  of  a  third 
sphincter  or  of  the  valves  of  the  rectum.  Indeed,  the  physiology 
of  the  act  of  defecation  itself,  which  we  have  just  described, 
goes  far  to  explain  why  there  should  be  a  certain  warning  of  an 
approaching  evacuation,  and  this  is  what  is  generally  meant 
when  the  patients  are  reported  to  have  a  certain  amount  of  con- 
trol over  the  movements.  The  control  will  be  found  in  most 
cases  to  mean  rather  a  consciousness  of  an  approaching  move- 
ment, a  warning  given  in  sufficient  time  to  allow  the  patient  to 
make  necessary  arrangements,  than  an  ability  to  absolutely 
prevent  the  evacuation  which  is  about  to  take  place.  Of  actual 
control  there  is  little,  because  the  sphincter  muscle,  whose  duty 
it  is,  under  the  power  of  the  will,  to  prevent  an  evacuation,  is 
absent.  To  the  performance  of  this  duty  a  healthy  sphincter  is 
abundantly  equal,  as  every  one  has  the  chance  to  prove  on  his 
own  person  ;  and  it  is  this  ability  to  delay  and  postpone  an 
evacuation  of  the  bowels,  rather  than  a  constant  action  in  pre- 
venting the  escape  of  faeces  which  are  ever  ready  to  escape, 
which  best  expresses  the  true  function  of  the  muscle.  After 
extirpation  of  the  anus,  this  one  element  of  natural  defecation 
is  destroyed,  but  several  others  are  left.  The  faeces  tend  to  re- 
main by  their  own  consistence  unless  actively  urged  forward  by 
the  peristalsis  of  the  bowel  ;  and  this  peristalsis  is  not  constant, 
but  recurs  periodically.  The  relative  increase  in  the  muscular 
elements  in  the  rectum  tends  to  keep  it  closed  and  empty  until 
faeces  are  forced  into  it  from  above.  Again,  the  pressure  of 
the  faeces,  owing  to  the  S-shaped  form  of  the  rectum,  is  not 


1  The  case  wa8  that  of  Fine,  of  Geneva,  in  1797.  "He  formed  an  artificial  anus, 
by  which  the  fa?cal  matters  escaped  not  continually,  but  once  or  twice  a  day  only,  and 
with  a  sensation  of  impending  necessity  which  gave  the  patient  time  to  make  the 
slight  preparations  ni-cessary  to  avoid  soiling  herself." — Manuel  de  M'.'d.  Pratique  de 
Le  Louis  Odier,  de  Geneve,  2me  ed  ,  1811. 


POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  35 

in  the  direction  of  the  axis  of  the  tube,  but  constantly  against 
the  wall,  and  at  the  points  of  greatest  curvature  the  resistance 
is  greatly  increased.  To  these  let  us  add  the  contraction  of  the 
cicatrix  after  extirpation,  and  the  natural  redundancy  of  the 
mucous  membrane  which  may  block  up  the  new  anus  by  an 
actual  prolapse,  and  we  have  the  factors  which  account  for  the 
clinical  fact  so  often  seen.  On  the  other  hand,  the  constant  es- 
cape of  faeces,  which  at  first  almost  always  follows  these  severe 
surgical  operations  upon  the  rectum,  is  best  explained  by  the 
irritation  of  the  wound  and  the  constant  reflex  action  which  it 
excites. 

That  the  folds  of  mucous  membrane,  such  as  have  been  de- 
scribed, are  of  the  nature  to  form  an  obstruction  to  the  passage  of 
the  faeces,  would  seem  to  admit  of  no  reasonable  doubt.  But  this 
obstruction  is  passive,  and  not  active,  and  is  by  no  means  sphinc- 
teric  in  character.  When  it  is  sufficiently  great  to  form  a  real 
obstruction  to  the  descent  of  faeces,  the  condition  is  an  abnormal 
one,  but  such  a  condition  is  sometimes  seen,  and  is  one  which  is 
not  to  be  disregarded  in  the  pathology  of  stricture  of  the  rectum. 

From  a  study  of  the  literature  of  this  question,  and  from  the 
results  of  dissections  and  experiments  which  we  have  personally 
been  able  to  make,  we  are  led  to  the  following  conclusions  : 

1.  What  has  been  so  often  and  so  differently  described  as  a 
third  or  superior  sphincter  ani  muscle  is  in  reality  nothing  more 
than  a  band  of  the  circular  muscular  fibres  of  the  rectum. 

2.  This  band  is  not  constant  in  its  situation  or  size,  and  may 
be  found  anywhere  over  an  area  of  three  inches  in  the  upper 
part  of  the  rectum. 

3.  The  folds  of  mucous  membrane  (Houston's  valves)  which 
have  been  associated  with  these  bands  of  muscular  tissue  stand 
in  no  necessary  relation  with  them,  being  also  inconstant,  and 
varying  much  in  size  and  position  in  different  persons. 

4.  There  is  nothing  in  the  physiology  of  the  act  of  defecation, 
as  at  present  understood,  or  in  the  fact  of  a  certain  amount  of 
continence  of  faeces  after  extirpation  of  the  anus,  which  neces- 
sitates the  idea  of  the  existence  of  a  superior  sphincter. 

5.  When  a  fold  of  mucous  membrane  is  found  which  con- 
tains muscular  tissue,  and  is  firm  enough  to  act  as  a  barrier  to 
the  descent  of  the  faeces,  the  arrangement  may  fairly  be  con- 
sidered an  abnormality,  and  is  very  apt  to  produce  the  usual 
signs  of  stricture. 


CHAPTER  II. 

CONGENITAL  MALFOEMATIONS  OF  THE  RECTUM  AND  ANUS. 

Separate  Development  of  Rectum  and  Anus. — Narrowing  of  the  Anus  or  Rectum 
without  Complete  Occlusion. — Congenital  Stricture. —  Closure  of  the  Anus  by  a 
Membranous  Diaphragm. — Entire  Absence  of  the  Anus,  the  Rectum  ending  in  a 
Blind  Pouch  at  a  Point  more  or  less  Distant  from  the  Perineum. — Rectum 
Same  as  in  Last  Variety  and  the  Anus  Normal. — Anus  Absent  and  Rectum  Open- 
ing by  an  Abnormal  Anus  at  Some  Point  in  the  Perineal  or  Sacral  Regions. — • 
Cases. — Anus  Absent  and  Rectum  Ending  in  the  Bladder,  Urethra,  or  Vagina. — 
Cases. — Rectum  and  Anus  Normal,  but  Ureters,  Uterus,  or  Vagina  Empty  into 
Rectum. — Total  Absence  of  Rectum. — Absence  of  Large  Intestine.- — Obliteration 
from  Intra-uterine  Disease. — Treatment. — Operation  should  always  be  Performed 
and  without  Delay. — Attempt  should  first  be  made  to  Establish  an  Anus  in  the 
Anal  Region. — Measurements  of  Pelvis  at  Birth. — Use  of  Trocar  not  Justifiable. — 
Useful  Anus  Seldom  Obtained  by  Means  of  Incision  Alone. — Objections  to  Cutting 
Operation  without  Plastic  Operation. — Proctoplasty. — If  Attempt  to  Establish 
New  Anus  in  Anal  Region  Pail,  Colotomy  at  once  to  be  Performed. — Inguinal 
Preferable  to  Lumbar  Colotomy. — History  of  Colotomy. — Callisen. — Amussat. — 
Description  of  Operation  of  Colotomy. — Dangers  of  Operation. — The  Inguinal 
Operation. — Description. — Attempts  at  Establishing  Anus  in  Anal  Region  after 
Colotomy  Generally  Unsuccessful. — Cases. — Closure  of  Artificial  Anus. — Opera- 
tion of  Dupuytren. — Modifications  of  Dupuytren's  Operation. — Byrd's  Operation. 

The  study  of  embryology  lias  revealed  the  fact  that  the  anus 
and  the  rectum  are  developed  separately.  The  anus  is  at  first 
represented  by  a  simple  depression  in  the  skin  of  the  perineum, 
which  gradually  extends  in  depth  and  advances  to  join  the  rec- 
tum. The  rectum  is  developed  in  connection  with  the  abdom- 
inal viscera,  gradually  separates  itself  from  them,  and  ending 
in  a  blind  pouch,  advances  to  meet  the  anal  depression.  At  the 
proper  time  the  two  coalesce  and  the  intestinal  canal  is  com- 
plete. This  process  of  development  of  either  the  rectum  or 
anus  may  be  arrested  at  almost  any  stage,  and  the  result  will 
be  one  of  the  various  malformations  which  are  now  to  be  de- 
scribed. 

These  congenital  malformations  have  been  classified  by  dif- 
ferent writers  into  various  groups.     We  shall  adoj)t,  in  the  fol- 


MALFORMATIONS    OF    THE    RECTUM    AND    ANUS.  37 

lowing  pages,  that  of  Papendorf,1  which  is  the  one  followed  by 
Bodenhamer,2  Molliere,3  and  Esmarch.4 

1.  Narrowing  of  the  Anus  or  Rectum  without  Complete  Oc- 
clusion.— A  congenital  stricture  of  the  anus,  or  of  the  rectum  at 
a  point  more  or  less  removed  from  the  anus,  has  been  occasion- 
ally reported.  Serremone  5  particularly  insists  upon  congenital 
narrowness  of  the  anus  as  a  cause  of  fissure,  and  has  himself 
observed  such  cases ;  and  the  same  condition  in  the  rectum  is 
generally  included  among  the  causes  of  benign  stricture. 

The  narrowing  in  these  cases  may  be  very  slight,  or  may 
reach  such  a  degree  as  hardly  to  admit  of  the  passage  of  meco- 
nium. It  is  generally  annular  in  form,  resembling  the  contrac- 
tion which  would  be  caused  by  tying  a  tape  tightly  around  the 
tube.  There  may  be  no  symptoms  caused  by  such  a  contrac- 
tion, and  the  child  may  grow  to  adult  life  suffering  only  froni 
obstinate  constipation ;  nor  do  such  contractions  lead  to  the 
ordinary  changes  in  the  mucous  membrane  above  and  below  the 
spot  which  are  usually  seen  in  cases  of  stricture  of  the  rectum. 
On  the  other  hand,  when  the  stricture  is  tight  it  will  give  rise  to 
all  the  usual  signs  of  such  a  condition  in  the  child — absence  of 
free  passage  of  meconium,  distention  of  the  abdomen,  and 
vomiting.  The  diagnosis  is  easily  made  by  a  digital  examina- 
tion should  the  symptoms  be  sufficiently  marked  to  lead  the 
attention  of  the  surgeon  to  the  rectum  ;  for  the  stricture  is  gen- 
erally near  the  anus  and  may  be  felt  as  a  ring  with  sharp  edges. 
The  treatment  consists  either  in  dilatation  or  in  nicking.6 

2.  Closure  of  the  Anus  by  a  Membranous  Diaphragm. — 
The  membrane  in  these  cases  may  be  of  greater  or  less  firmness 
and  thickness,  and  may  be  composed  of  skin  or  of  mucous 
membrane.     It  is  sometimes  so  thin  as  to  bulge  out  with  meco- 

1  Dissertatio  sistens  observationes  de  ano  infantum  imperforato.  Lugd.  Batav., 
1781,  4to  (Bodenhamer). 

2  A  Practical  Treatise  on  the  Etiology,  Pathology,  and  Treatment  of  the  Con- 
genital Malformations  of  the  Rectum  and  Anus,  by  Wm.  Bodenhamer.  New  York : 
Wm.  Wood  &  Co.,  1860. 

3  Traite  des  Maladies  du  rectum  et  de  l'anus,  par  Daniel  Molliere.     Paris,  1877. 
1  Op.  cit. 

6  Inaugural  Thesis,  No.  555.     Strasbourg,  1861. 

8  See  also  Gosselin,  Clinique  Chirurg.,  3d  ed.  Paris,  1879.  t.  iii.,  p.  706.  Berard 
et  Maslieurat-Lagemar,  Gaz.  Med.  de  Paris,  1839,  p.  146.  Demarquay,  Journal  de 
1' experience,  t.  ix.,  1842,  p.  273.  Ashton,  Diseases  of  the  Rectum,  London,  1854,  p. 
27.     DeviUiers,  Rev.  Med.  de  Paris,  1835. 


38 


DISEASES    OF    THE    KECTUM    AND    ANUS. 


nium  when  the  child  strains  or  coughs,  and  has  been  known  to 
rupture  spontaneously. 

This  is  the  simplest  of  all  the  forms  of  congenital  malforma- 
tion of  the  anus,  and,  unfortunately,  one  of  the  rarest.  It  is 
easily  diagnosticated  by  simple  inspection  of  the  parts  ;  and 
the  treatment  consists  in  making  a  crucial  incision  through  the 
membrane.  The  remains  of  the  membrane,  like  those  of  the 
hymen,  which  it  strongly  resembles,  will  shrink  up  so  as  not  to 
cause  trouble  or  deformity. 

3.  Entire  Absence  of  the  Anus,  the  Rectum  ending  in  a 
Blind  Pouch  at  a  Point  more  or  less  Distant  from  the  Peri- 
neum.— In  these  cases  there  may  be  a  slight  depression  at  the 


Fig.  7.— Rectum  ending  in  a  Blind  Pouch.     (Molliere.) 

point  where  the  anus  should  be  found  ;  or  there  may  be  no 
trace  of  the  anal  orifice,  the  raphe  of  the  perineum  extending 
over  the  spot  and  back  to  the  coccyx.  The  external  sphincter 
muscle  is  also  sometimes  present,  and  at  others  entirely  want- 
ing. The  pouch  of  the  rectum  in  these  cases  may  hang  loose  in 
the  pelvis  or  abdominal  cavity,  or  be  attached  to  some  adjacent 
part ;  and  the  space  between  it  and  the  perineum  may  be  filled 
up  with  cellular  tissue,  or,  in  other  cases,  a  distinct  fibrous  cord 
may  be  traced  from  the  rectal  pouch  to  the  skin,  as  is  shown  in 
the  plate  (Pig.  7). 


MALFORMATIONS    OF    THE    RECTUM    AND    ANUS. 


39 


If  the  pouch  of  the  rectum  be  not  at  too  great  a  distance 
from  the  skin,  a  sense  of  fluctuation  may  be  felt  by  firm  press- 
ure with  one  finger  over  the  anus  and  the  other  hand  on  the 
abdomen.  In  females,  valuable  aid  in  diagnosis  may  be  ob- 
tained by  the  introduction  of  a  finger  into  the  vagina.  The  use 
of  a  stethoscope  over  the  anus,  and  of  percussion  on  the  abdo- 
men, has  been  recommended  to  detect  the  rectal  pouch  filled 
with  gas  (Bodenhamer,  Molliere) ;  and  also  the  irritation  of  the 
skin  over  the  anus  to  provoke  efforts  at  defecation.1  An  effort 
should  always  be  made,  where  there  is  complete  absence  of  the 
anus,  to  discover  whether  the  rectum  may  not  have  some  out- 
let through  the  bladder  or  vagina,  which  shall  place  the  case  in 
one  of  the  classes  soon  to  be  described. 


Fig.  8. — Rectum  ending  in  Blind  Pouch  ;  Anus  Normal.     (Molliere.) 

4.  The  Rectum  may  be  the  Same  as  in  the  Last  Variety,  and 
the  Anus  be  Normal.  Fig.  8. — The  septum  which  separates  the 
rectal  and  anal  pouches  in  this  case  is  generally  within  easy 
reach  of  the  anus,  and  may  be  so  thin  as  to  permit  a  sense  of 
fluctuation.  In  most  cases,  however,  the  septum  is  thicker,  and 
is  composed  of  cellular  or  fibrous  tissue,  lined  both  above  and 
below  by  mucous  membrane.  It  may  be  perforated,  like  the 
hymen,  at  some  point,  and  allow  of  the  slow  dribbling  of  meco- 


1  A.  Copeland  Hutchinson  :  Practical  Observations  in  Surgery.     London,  1826. 


40 


DISEASES    OF    THE    EECTUM    AND    ANUS. 


ilium.  There  may  also  be  more  than  one  septum.  Voillemier  ? 
reports  one  case  in  which  the  rectum  was  divided  in  this  way 
into  four  distinct  compartments,  the  upper  one  containing 
meconium,  and  the  others  mucus.  There  is  generally  little 
difficulty  in  the  diagnosis  of  these  cases,  provided  only  a  digital 
examination  be  made  when  the  infant  begins  to  show  the  effects 
of  the  obstruction  ;  but  the  danger  lies  in  the  fact  of  the  normal 
anus,  which  is  apt  to  allay  suspicion  as  to  the  true  nature  of 
the  difficulty.2 

5.   Tlie  Anus  may  be  Absent,  and  the  Rectum  may  Open  by  an 
Abnormal  Anus  at  any  point  in  the  Perineal  or  Sacral  Region. 


Fig.  9. — Rectum  ending  in  Glans  Penis.     (Molliere.) 

— When  the  rectum  terminates  in  the  glans  penis,  the  labia,  or 
at  some  abnormal  point  in  the  perineum,  the  lower  portion  of  it 
is  usually  of  a  fistulous  character,  as  shown  in  the  plate  (Fig.  9), 
but  lined  by  true  mucous  membrane  ;  and  the  anus,  whether  in 
the  perineum  or  at  the  base  of  the  sacrum,  or  tip  of  the  coccyx, 


1  Gaz.  desHop.,  1846. 

2  "Dr.  H.  G-.  Jameson,  of  Baltimore  (Medical  Recorder,  vol.  v.,  1822,  p.  290), 
divided  two  membranous  septa,  one  above  tbe  otber,  witb  a  button-headed  bistoury, 
which  he  passed  '  into  the  opening  or  ring  of  the  septum,'  and  with  which  he  cut  freely 
down  toward  the  sacrum.  This  was  done  in  September,  1821.  The  patient  got  well. 
Roser  fArch.  fur  Physiol.  Heilkunde,  1859,  p.  125)  mentions  a  circular  valvular  strict- 
ure an  inch  from  the  anus,  in  a  little  girl  of  four,  which  he  treated  by  division." — Van 
Buren  :  Lectures  upon  Diseases  of  tbe  Rectum  and  the  Surgery  of  the  Lower  Bowel. 
New  York  :  D.  Appleton  &  Co.,  1881,  p.  263,  note. 


MALFORMATIONS    OF    THE    RECTUM    AND    ANUS.  41 

is  always  narrow  and  insufficient  for  its  purpose.  A  modifica- 
tion of  this  class  of  abnormalities  is  found  in  those  cases  where 
the  rectum  terminates  in  two  openings  at  a  greater  or  less  dis- 
tance from  each  other. 

Cruveilhier '  reports  a  case  of  this  nature,  in  which  the  fistu- 
lous prolongation  of  the  rectum  ran  subcutaneously  in  the  scro- 
tal raphe  and  terminated  at  the  glans  penis. 

Mr.  Morgan2  has  recently  reported  two  modifications  of  this 
species  of  deformity  which  are  rarely  met  with,  and  are  easily 
relieved.  In  the  first  the  anus  was  of  the  usual  size  and  in  the 
proper  location ;  but  there  was  found  to  be  a  band  of  tissue 
passing  from  a  point  corresponding  to  the  apex  of  the  coccyx 
to  the  median  raphe  of  the  scrotum,  with  the  posterior  ex- 
tremity of  which  it  was  continuous.  The  band  was  about  three- 
quarters  of  an  inch  long,  and  was  attached  at  both  ends,  the  re- 
mainder forming  a  thick,  free  cord,  which  lay  below  the  aperture 
of  the  anus,  while  from  the  centre  of  this  band  there  ran  a  small 
branch  of  similar  tissue,  which  was  attached  to  the  skin  of  the 
left  buttock,  and  was  about  half  an  inch  in  length.  The  skin 
covering  the  central  band  exactly  resembled  that  of  the  scro- 
tum, shrinking  and  contracting  upon  stimulation,  and  it  was  so 
placed  that  any  passage  of  faeces  must  cause  it  to  be  stretched, 
thus  accounting  for  the  pain  attending  each  motion  of  the  bowels. 

The  second  case  was  similar.  The  child  was  born  with  an 
imperforate  anus,  but  the  membranous  septum  gave  way  spon- 
taneously. The  child,  however,  continued  to  suffer  pain  on 
defecation,  and  on  examination  there  was  seen  a  small,  thick 
band  passing  from  the  median  raphe  of  the  perineum  in  front  to 
the  depression  between  the  buttocks  posteriorly,  and  broadest 
behind.  At  a  spot  corresponding  to  the  anus,  on  either  side  of 
the  band,  was  a  depression  :  that  on  the  right  was  patent,  and 
allowed  a  probe  to  pass  into  the  anus  ;  that  on  the  left,  though 
similar  in  appearance,  proved  to  be  only  a  cul-de-sac. 

In  a  third  case  there  was  a  depression  at  the  usual  site  of 
the  anus,  and  the  parts  around  were  so  far  natural  that  the  skin 
was  pigmented  and  puckered,  but  there  was  no  communication 
with  the  rectum.  The  spot  at  which  the  fa3ces  passed  was  in 
the  median  line  half-way  between  this  depression  and  the  pos- 

1  Anat.  Pathologique  du  Corps  Humain,  t.  i.,  Liv.  i.,  Planche  vi. 

2  Three  Cases  of  Unusual  Deformity  of  the  Anus.     Lancet,  October  22,  1881. 


42 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


terior  commissure,  but  nearer  the  latter  than  the  former.  The 
opening  was  very  small,  and  a  probe  passed  up  into  it  showed 
an  abundance  of  tissue  between  the  passage  and  the  vagina. 
The  cure  consisted  in  enlarging  this  abnormal  opening  posteri- 
orly into  the  depression  representing  the  natural  one.  Delans ' 
reports  an  analogous  case  in  a  well-nourished  child  aged  four 
and  a  half  years.  There  were  two  openings,  one  on  each  side  of 
a  median  bridle,  which  was  continuous  with  the  raphe  in  front 
and  behind,  and  was  composed  only  of  skin  and  mucous  mem- 
brane. Each  opening  seemed  to  be  the  natural  one,  but  the 
one  on  the  left  was  a  cul-de-sac  fifteen  millimetres  deep.  The 
septum  was  excised,  with  what  result  is  not  stated. 


FlG.  10. — Rectum  ending  in  Bladder.     (Molliere.) 


6.  Tfie  Anus  may  be  Absent  and  the  Rectum  may  end  in  the 
Bladder,  Urethra,  or  Vagina.  Fig.  10. — Of  these  varieties,  that 
in  which  the  rectum  opens  into  the  vagina  is  the  most  common. 
In  females  the  opening  is  seldom,  if  ever,  into  the  bladder,  but 
sometimes  it  is  into  the  urethra.  In  males  it  is  more  often  into 
the  bladder  than  into  the  urethra,  and  in  such  cases  the  rectum 
may  terminate  either  by  a  narrow  duct  running  obliquely 
through  the  bladder  and  opening  in  the  bas-fond  between  the 
orifices  of  the  ureters,  or  by  a  free  opening.     The  symptoms  of 


1  Soc.  de  Chirurgie,  March  24,  1875. 


MALFORMATIONS    OF    THE    RECTUM    AND    ANUS.  43 

this  condition  will  of  course  vary  greatly  according  to  the  loca- 
tion of  the  abnormal  opening.  When  the  communication  is  be- 
tween the  rectum  and  bladder  the  fact  will  be  shown  by  the 
mixture  of  the  meconium  with  the  urine,  rendering  the  latter 
thick  and  greenish  in  color.  The  amount  of  meconium  pres- 
ent will  also  indicate  whether  the  opening  is  large  or  small. 
This  condition  is  generally  fatal,  from  the  development  of  cys- 
titis and  from  intestinal  obstruction  unless  the  condition  be  re- 
lieved by  the  appropriate  surgical  interference.1 

When  the  communication  is  urethral  in  the  male,  the  meco- 
nium will  often  escape  independently  of  the  act  of  urination. 
The  prognosis  is  not  as  bad  in  these  cases  as  in  the  vesical  vari- 
ety, several  being  recorded  in  which  life  has  been  preserved  for 
a  number  of  years.  Gross  2  relates  one  case  in  a  man  aged 
thirty,  and  Bodenhamer  cites  several  others  in  which  children 
have  lived  three  or  four  years. 

In  the  female  the  prognosis  is  more  favorable  than  in  the 
male,  from  the  greater  facility  with  which  the  meconium  es- 
capes. 

Where  the  abnormal  opening  is  between  the  vagina  and  rec- 
tum, and  is  of  considerable  size,  as  it  generally  is,  the  prognosis 
is  not  necessarily  grave.  Women  have  been  known  to  live  to  a 
good  old  age,  even  to  reach  one  hundred  years  in  the  case  of 
Morgagni,  with  this  malformation,  and  to  perform  all  the  duties 
of  wives  and  mothers  without  even  being  conscious  of  anything 
abnormal  (Founder,3  Ricord). 

7.  The  Rectum  and  Anus  are  Normal,  but  the  Ureters, 
Uterus,  or  Vagina  Empty  into  the  Rectal  Cavity  and  Dis- 
charge their  Contents  through  it. — This  species  of  malformation 
is  rare,  and  is  usually  attended  by  other  signs  of  imperfect  de- 
velopment.    It  is  not  incompatible  with  life  or  with  conception. 

8.  Total  Absence  of  the  Rectum. — This  variety  differs  only 
from  the  third  in  the  amount  of  the  rectum  which  may  be  ab- 
sent. It  may  or  may  not  be  attended  by  an  absence  of  the 
anus,  but  is  usually  only  one  of  the  signs  of  arrested  develop- 

1  As  showing  what  the  bladder  and  urethra  may  bear,  however,  Rowan's  case  is  of 
great  interest.  In  ifc  defecation  took  place  through  the  penis  for  two  months  without 
causing  any  signs  of  irritation,  though  the  child  was  several  months  old,  and  the  rec- 
tum was  filled  with  well-formed  hard  fasces. — Australian  Medical  Journal,  March,  1877. 

2  A  System  of  Surgery.     H.  C.  Lea,  Philadelphia,  1872,  vol.  ii.,  p.  657. 

3  Diet,  des  Sci.  Med.,  t.  iv.,  p.  155. 


44  DISEASES    OF   THE    RECTUM    AND    ANUS. 

nient.  The  blind  pouch  of  the  rectum  may  hang  loose  in  the 
abdomen  or  pelvis  ;  may  be  attached  in  the  base  of  the  sacrum, 
or  to  some  of  the  adjacent  parts  ;  or  may  be  continued  down  as 
a  fibrous  cord  to  the  site  of  the  anus. 

9.  Absence  of  the  Large  Intestine. — This  is  also  attended  by 
an  absence  of  the  normal  anus,  the  place  of  which  is  supplied 
by  an  abnormal  opening  in  the  umbilicus,  or  at  some  remote 
pair  of  the  body,  as,  for  example,  the  side  of  the  chest,  or  the 
face.  With  this  abnormal  opening  the  small  intestine  or  what 
remains  of  the  colon  communicates. 

Thus  far  only  arrests  or  excesses  of  development  have  been 
mentioned.  The  rectum  and  anus  are,  however,  liable  to  certain 
diseases  during  foetal  life  which  may  result  in  narrowing  or 
completely  obliterating  their  calibre.  Among  these  are  enteritis 
and  proctitis. 

Treatment. — The  treatment  of  the  class  of  congenital  con- 
tractions of  the  anus  and  rectum,  and  of  the  class  of  membra- 
nous septa,  has  already  been  referred  to,  and  is  exceedingly 
simple  and  generally  attended  by  good  results.  The  treatment 
of  the  remaining  varieties,  except  the  eighth  and  ninth,  which 
do  not  admit  of  surgical  interference,  may  be  guided  by  the  fol- 
lowing general  propositions. 

1.  An  Operation  should  always  be  Performed  and  Per- 
formed without  Delay. — There  is  little  to  be  gained  even  by 
waiting  for  the  rectal  pouch  to  become  distended  with  meconium, 
and  there  is  much  to  be  lost.  If  the  obstruction  be  complete, 
death  is  a  necessary  result,  being  produced  by  peritonitis,  rup- 
ture of  the  over-distended  bowel,  or  by  a  gradual  wasting  with- 
out acute  symptoms.  Even  in  cases  where  a  certain  amount  of 
meconium  makes  its  escape  by  a  narrow  orifice,  and  delay  is 
not,  therefore,  as  necessarily  dangerous  as  in  cases  of  complete 
obstruction,  nothing  is  to  be  gained  by  delay,  and  an  immediate 
operation  may  avoid  a  paralysis  of  the  bowel  from  over-dis- 
tention.1 


1  Cripps  (Lancet,  May  15,  1880)  has  reported  a  most  remarkable  case  bearing  upon 
this  point.  The  condition  of  imperforate  rectum  was  diagnosticated  on  the  third  day, 
but  operation  was  refused  and  the  child  taken  from  the  hospital.  Thirty  days  later 
she  was  brought  back  again  apparently  quite  well ;  the  abdomen  was  distended  ;  food 
was  taken  well,  but  three  or  four  times  every  day  she  vomited  faecal  matter.  In 
this  case,  the  anus  terminated  in  a  blind  pouch  and  a  trocar  was  plunged  upward 
through  it.     Only  a  little  serous  fluid  escaped  from  the  peritoneal  cavity,  and  the  child 


MALEOKMATIOISTS    OF   THE    KECTUM    AND    ANUS.  45 

2.  If  there  be  any  Chance  of  establishing  an  Opening  at  the 
Normal  Site  of  the  Anus,  the  Surgeon  should  at  first  direct  his 
Attention  to  this  Procedure. — And  since  in  most  cases  it  is  im- 
possible to  tell  that  the  rectal  pouch  may  not  be  within  easy 
reach  from  the  perineum,  it  is  generally  good  surgery  to  make 
a  tentative  incision  at  this  point. 

Before  attempting  any  operation  on  a  child's  pelvis,  the  sur- 
geon should  remember  the  exceeding  smallness  of  the  space  in 
which  he  is  obliged  to  work,  even  in  its  natural  state  ;  and  also 
that  the  normal  measurements  may  be  decreased  in  any  case  of 
congenital  malformation.  These  normal  measurements,  accord- 
ing to  Bodenhamer,  who  made  them  on  two  new-born,  well-de- 
veloped male  infants  at  full  term  are  as  follows  : 

First  case  :  From  one  tuberosity  of  the  ischium  to  the  other, 
one  inch  and  one  line.  From  the  os  coccygis  to  the  symphysis 
pubis,  one  inch  and  three  lines.  From  the  os  coccygis  to  the 
promontory  of  the  sacrum,  one  inch  and  two  lines. 

Second  case :  From  one  tuberosity  of  the  ischium  to  the 
other,  one  inch.  From  the  os  coccygis  to  the  symphysis  pubis, 
one  inch  and  one  line  and  a  half.  From  the  os  coccygis  to  the 
promontory  of  the  sacrum,  one  inch  and  one  line. 

The  means  at  the  disposal  of  the  operator  for  reaching  the 
rectal  pouch  through  the  perineum  and  establishing  a  new  out- 
let consists  in  puncture,  incision  (proctotomy),  and  in  the  form- 
ation of  a  new  anus  by  a  plastic  operation  (proctoplasty).  The 
operation  by  puncture  consists  in  plunging  a  trocar  through  the 
perineum  in  the  supposed  direction  of  the  rectum,  for  the  pur- 
pose of  establishing  an  outlet.  It  may  be  done  without  a  pre- 
liminary incision,  or  after  a  careful  dissection  which  has  failed 
to  reach  the  desired  point. 

3.  The  Use  of  a  Trocar  as  an  Aid  in  finding  the  Rectal 
Pouch  before  or  after  Incisions  through  the  Perineum  is  not 
sanctioned  by  Modern  Surgical  Authority. — It  is  a  procedure 
attended  with  the  greatest  danger  to  the  life  of  a  patient,  and 
when  the  rectal  pouch  is  successfully  reached,  which  is  rare,  the 
outlet  thus  made  is  of  little  use.     The  peritoneum,  bladder,  or 


died  of  peritonitis.  At  the  autopsy,  the  rectal  cul-de-sac  was  found  just  above  the 
anal  pouch,  but  the  trocar  had  penetrated  the  peritoneal  pouch  between  the  two. 
There  are  two  noteworthy  points  in  the  case.  The  first  is  the  remarkable  manner  in 
which  nature  accommodated  itself  to  the  deformity;  and  the  second  is  the  ease  with 
which  the  rectal  pouch  may  be  missed  with  a  trocar. 


46  DISEASES    OF   THE    EECTUM    AND    ANUS. 

uterus  may  each  be  wounded  by  the  instrument  with  a  fatal 
result ;  the  opening  made  is  not  free  enough  to  allow  of  easy 
escape  of  meconium  ;  nor  can  such  an  opening  be  made  to 
serve  the  purpose  of  rectum  and  anus  by  any  subsequent  dila- 
tation. 

4.  The  Results  of  Attempts  to  establish  an  Outlet  for  an  Im- 
perfect Rectum  by  means  of  Incisions  alone  through  the  Peri- 
neum are  not  favorable  as  regards  the  production  of  a  Useful 
Anus, — The  operation  consists  in  cutting  through  the  perineal 
tissues,  stroke  by  stroke,  until  the  rectal  pouch  is  reached  and 
opened.  The  incision  should  be  longitudinal,  and  should  reach 
from  the  scrotum  to  the  tip  of  the  coccyx.  Should  the  fibres 
of  the  external  sphincter  be  encountered  beneath  the  skin,  they 
may  be  carefully  separated  as  near  the  median  line  as  possible 
and  drawn  to  each  side.  The  direction  of  the  dissection,  which 
it  is  needless  to  say  should  be  made  with  the  utmost  care, 
should  be  backward  toward  the  concavity  of  the  sacrum  in  the 
line  which  the  rectum  normally  follows.  Additional  safety 
may  be  secured  by  the  introduction  of  a  sound  into  the  male 
bladder  or  the  female  vagina.  The  finger  is  to  be  frequently 
used  as  a  director  in  exploring  for  the  rectal  pouch,  while  the 
hand  of  an  assistant  makes  pressure  on  the  abdomen.  In  this 
way  the  dissection  may  be  carried  to  the  depth  of  an  inch  or  pos- 
sibly an  inch  and  a  half,  but  at  this  point,  if  unsuccessful,  it 
should  be  abandoned  for  fear  of  wounding  the  peritoneum. 

This  operation,  though  it  may  be  successful  in  allowing  the 
escape  of  meconium,  and  in  prolonging  life,  does  not,  in  most 
cases,  result  in  a  useful  anus  for  any  great  number  of  years. 
This  is  the  experience  of  the  greater  number  of  writers  upon 
this  subject.  Van  Buren1  says:  "I  have,  in  several  instances, 
succeeded,  by  careful  dissection,  in  reaching  a  fluctuating  point 
of  a  blind  rectal  pouch,  and  in  establishing  a  free  outlet  for  the 
meconium,  but  in  no  case  has  it  proved  permanently  useful. 
It  has  always  been  necessary  to  employ  bougies  or  tents  more 
or  less  constantly  to  keep  the  new  canal  from  contracting,  and 
the  care,  and  pain,  and  trouble  of  fighting  against  the  closing 
stricture,  and  the  persistent  tendency  to  obstruction  and  faecal 
accumulation  have  invariably  led  to  early  death.  At  present,  I 
know  of  no  such  case  treated  in  this  way,  in  which  a  perma- 

1  Op.  cit.,  p.  371. 


MALFORMATIONS    OF   THE    RECTUM    AND    ANUS.  47 

nently  satisfactory  result  has  been  attained."  Amussat,'  Sir 
Benjamin  Brodie,  Velpeau,2  Benjamin  Bell,3  and  many  others, 
have  borne  testimony  to  the  same  effect  On  the  other  hand, 
cases  are  occasionally  seen  where  the  result  is  more  favorable, 
but  they  constitute  a  small  minority  of  the  whole.  What  the 
operation  really  accomplishes  is  the  formation  of  a  fsecal  fistula, 
with  all  the  discomforts  attendant  upon  such  a  condition. 

It  was  this  difficulty,  combined  with  the  loss  of  two  cases  in 
which  the  operation  had  been  performed  from  blood-poisoning 
with  jaundice,  which  Amussat  considered  to  be  due  to  the  ab- 
sorption of  meconium  and  fsecal  matter  by  the  freshly  cut  sur- 
face, which  led  him  to  abandon  this  operation,  and  to  substitute 
in  its  place  the  one  now  to  be  described. 

Operation  of  Amussat.  Proctoplasty. — This  operation  is  the 
same  as  the  last,  with  the  addition  of  two  important  features. 
In  the  first  place,  the  rectum  is  drawn  down  and  stitched  to  the 
skin  ;  and,  second,  to  facilitate  this,  when  necessaiy,  the  new 
anus  is  made  either  just  at  the  tip  of  the  coccyx,  or  that  bone  is 
exsected  and  the  anus  made  in  the  place  it  occupied.  Where 
much  of  the  lower  end  of  the  rectum  is  deficient,  it  may  not  be 
possible  to  draw  the  cul-de-sac  down  to  the  skin  without  more 
traction  and  dissection  than  it  is  safe  to  employ.  In  such  cases 
the  excision  of  the  coccyx,  as  originally  recommended  and  prac- 
tised by  Amussat,4  and  more  recently  by  Yerneuil, s  besides  add- 
ing to  the  chances  of  finding  the  rectal  pouch,  diminishes  the 
distance  over  which  the  rectum  must  be  stretched.  Unfortu- 
nately, in  the  cases  where  the  operation  is  most  needed — those 
in  which  the  rectal  pouch  is  furthest  from  the  skin — the  opera- 
tion is  not  always  practicable  ;  and  in  other  cases  the  adhesions 
of  the  rectum  to  the  bladder  or  vagina  may  be  an  insuperable 
obstacle.  In  the  latter  class  of  cases,  however,  a  new  anus  may 
be  formed,  and,  if  successful,  the  recto-vaginal  fistula  may  be 
closed  by  subsequent  operations. 

5.  In  Case  of  Failure  to  Establish  a  New  Anus  in  the  Anal 

1  Observation  sur  une  Operation  d'  Anus  artificiel,  etc.  Gaz.  Med.  de  Paris,  No- 
vember 28,  1835,  p.  753. 

8  Nouveau  Elements  de  Med.  Operatoire.     Paris,  1832. 

3  A  System  of  Surgery,  vol.  ii.,  chapter  xix.     Edinburgh,  1778. 

4  Troisieme  Memoire  sur  la  Possibility  d'etablir  une  ouverture  artificielle  sur  la 
colon  lombaire  gauche  sans  ouvrir  la  Peritoine,  chez  les  enfans  imperfores.  Paris, 
1842. 

6  Gaz.  des  Hop.  de  Paris,  July  29,  August  5,  1873,  pp.  004,  715. 


48  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Region,  ('ototomy  should  at  once  be  Performed. — The  teachings 
of  different  authorities  will  vary  as  to  the  propriety  of  first  per- 
forming the  perineal  operation  before  resorting  to  colotomy, 
according  to  the  views  of  each  one  upon  the  question  of  the 
desirability  of  colotomy.  Some  follow  the  rule  I  have  laid 
down,  that  it  is  always  better  to  attempt  the  perineal  operation 
where  there  is  a  chance  of  its  succeeding  ;  others  limit  the  lat- 
ter operation  to  cases  where  the  rectal  pouch  is  known  to  be 
near  the  skin,  and  in  all  others  turn  their  efforts  at  once  toward 
the  colon.  The  abdominal  operation  is  obviously  the  only  one 
where  the  rectum  ends  high  up  in  the  pelvis,  and  it  is  generally 
Jo  be  preferred  in  that  class  of  cases  where  it  opens  into  the 
bladder  or  urethra. 

6.  In  the  Formation  of  an  Artificial  Anus,  tlie  Left  Groin  is 
the  Best  Site  for  the  Operation. — The  colon  may  be  opened  either 
in  the  loin  or  groin,  and  on  either  the  left  or  right  side.  There 
is  some  uncertainty  in  the  early  history  of  colotomy  and  some 
ambiguity  of  terms,  which  is  apt  to  mislead.  The  idea  of  an 
artificial  anus  was  first  proposed  hy  Littre,1  in  1710,  and  the  in- 
cision he  recommended  was  simply  "  au  ventre'1''  (in  the  abdo- 
men) ;  the  design  being  to  reach  the  sigmoid  flexure.  He  never 
practised  the  operation  which  at  present  passes  under  his  name 
— that  of  opening  the  bowel  in  the  groin — nor  did  the  operation 
he  proposed  involve  the  idea  of  preserving  the  peritoneum  intact. 

About  the  }Tear  1770  Pillore,  of  Rouen,  actually  performed 
the  first  operation  of  this  nature,  by  making  an  opening  into 
the  caecum  in  a  case  of  cancer  of  the  rectum  which  caused  com- 
plete obstruction.  The  patient  survived  twenty -eight  days,  and 
death  was  not  due  to  the  operation.  In  1783  Dubois  operated 
in  the  same  way  for  imperforate  anus,  but  the  operation  was 
unsuccessful,  and  the  child  died  on  the  tenth  day.  In  1793 
Duret,  of  Brest,  opened  the  sigmoid  flexure  of  a  child  two  days 
old,  and  this  child  lived  to  adult  age.  In  1794  Desault  prac- 
tised the  same  operation  without  success,  and  in  1797  Fine,  of 
Geneva,  made  an  artificial  anus  in  the  arch  of  the  colon  for 
cancer  of  the  upper  part  of  the  rectum,  which  was  also  success- 
ful, the  woman  living  three  months  and  a  half.*    In  1814  the 


1  Histoire  de  L'Acad.  Roy.  des  Sci.  de  Paris,  1710,  p.  36. 

■  Manuel  de  mc'd.  prat,  de  Louis  Adier  de  Geneve.  2d  edit.,  1811.  Quoted  by 
Carcopino,  These  No.  107,  1879.  "Parallel  eutre  l'extirpation  du  rectum  et  lY-ta- 
blissement  de  l'anua  artificiel." 


MALFORMATIONS    OF    THE    RECTUM    AND    ANUS.  49 

operation  was  successfully  performed  for  cancer  of  the  rectum 
by  Martland  ; '  in  1817  by  Freer,  of  Birmingham  ; 2  and  in  1820 
by  Pring.3  In  many  of  these  cases  the  original  operation  of 
Littre  was  modified  to  suit  the  operator  *,  but  in  none  of  them 
was  any  attention  paid  to  wounding  the  peritoneum. 

An  undue  prominence  seems  to  attach  to  the  name  of  Callisen 
in  connection  with  the  operation  in  the  left  loin.  There  was 
nothing  original  in  his  choice  of  location,  nor  did  he  bring  out 
the  idea  of  operating  without  wounding  the  peritoneum.  He 
believed  that  the  intestine  could  be  more  easily  reached  from 
this  point  than  any  other,  in  which  he  certainly  was  in  error  ; 
and  on  the  whole  he  condemned  the  operation  in  the  following 
words :  *  "  The  incision  of  the  caecum  and  descending  colon, 
wliich  has  been  proposed,  in  this  state  of  things  (imperforate 
rectum),  by  means  of  an  incision  in  the  left  lumbar  region  at  the 
border  of  the  quadratus  lumborum,  to  establish  an  artificial 
anus,  presents  a  very  uncertain  chance,  and  the  life  of  the  little 
patient  can  scarcely  be  saved ;  nevertheless,  the  intestine  may 
be  reached  more  easily  in  this  place  than  above  in  the  iliac 
region." 

It  is  in  reality  to  Amussat  that  the  extra-peritoneal  operation 
in  the  loin  is  due,  and  the  operation  which  he  described  '*  is  the 
one  now  in  favor  and  the  one  usually  spoken  of  as  that  of 
Callisen. 

The  guide  to  the  descending  colon  is  the  outer  border  of  the 
quadratus  lumborum  muscle,  and  the  guide  to  the  outer  bor- 
der of  the  muscle  is  a  perpendicular  from  a  point  one-half  inch 
posterior  to  the  middle  of  the  crest  of  the  ilium,  or  to  a  point 
half  an  inch  posterior  to  the  middle  of  a  line  drawn  from  the 
anterior  superior  to  the  posterior  superior  spinous  process. 
This  point  should  first  of  all  be  accurately  determined  and 
marked  with  ink  or  iodine,  for  the  edge  of  the  muscle  cannot 
easily  be  felt  in  many  subjects.  The  descending  colon  is  here 
in  great  part  uncovered  by  peritoneum,  being  behind  that  mem- 
brane and  in  immediate  contact  with  the  transversalis  fascia. 
The  patient  should  be  placed  upon  a  hard  pillow,  so  that  the 

1  Edinburgh  Med.  and  Surg.  Jour.,  October,  1825,  p.  271. 

2  Carcopino.      These.  3  London  Med.  and  Physical  Journal,  1821. 

4  Systema  Chirurgias  hodiernse,  t.  i.     Haffiniae,  1813. 

5  Quelques   reflexions   pratiques   sur  les  retrecissements  du  rectum.     Gaz.    Med. 
de  Paris,  1839,  No.  1. 

4 


50  DISEASES    OF    THE    RECTUM    AND    ANUS. 

loin  may  be  brought  into  prominence,  and  the  operator  should 
stand  at  the  back  of  the  patient. 

The  incision  should  cross  the  edge  of  the  quadratus  obliquely 
from  above  downward  and  from  behind  forward,  beginning  at 
the  left  of  the  sjDine  below  the  last  rib,  and  extending  four  or 
five  inches.  In  this  way  the  middle  of  the  outer  border  of  the 
muscle  will  correspond  to  the  middle  of  the  incision,  and  the 
large  branches  of  the  spinal  nerves  will  not  be  severed.  The  in- 
cision is  then  carried  carefully  down,  layer  by  layer,  through 
the  latissimus  dorsi,  external  and  internal  oblique,  and  trans- 
versalis  muscles,  till  the  outer  border  of  the  quadratus  is  recog- 
nized ;  care  being  taken  that  as  the  incision  grows  deeper  it 
does  not  also  grow  shorter,  till  when  the  bowel  is  reached  the 
operator  finds  himself  working  in  the  small  end  of  the  funnel. 
If  possible  the  outer  border  of  the  quadratus  should  be  dis- 
tinctly recognized  before  the  transversalis  fascia  is  divided, 
under  which  lies  the  colon  more  or  less  enveloped  in  fat.  When 
distended  either  artificially  by  air,  or  by  the  faeces,  it  is  recog- 
nized either  by  the  feel  of  the  faeces  or  by  its  longitudinal  mus- 
cular bands.  "When,  on  the  other  hand,  it  is  collapsed  (and  it 
may  be  collapsed  even  in  cases  of  prolonged  retention,  the  ac- 
cumulation being  either  above  or  below  the  point  of  operation), 
the  patient  may  be  turned  on  the  back  to  allow  it  to  fall  into 
the  wound,  or  pressure  may  be  made  on  the  abdomen  by  an  as- 
sistant. Bryant  recommends  rolling  the  bowel  partially  for- 
ward after  it  has  been  seized,  to  bring  its  posterior  surface  into 
the  wound,  as  an  additional  safeguard  against  wounding  the 
peritoneum. 

When  the  bowel  has  been  drawn  well .  out  to  the  surface  of 
the  wound  it  must  be  secured  in  position  before  it  is  opened,  in 
order  that  its  contents  may  not  escape  into  the  abdominal  cavity. 
This  is  best  done  by  passing  a  couple  of  ligatures  through  it  and 
the  lips  of  the  wound  in  the  following  manner.  The  needle  is 
entered  on  one  side  of  the  incision  and  carried  through  the  in- 
tegument alone,  and  not  through  the  whole  thickness  of  the 
abdominal  wall,  for  the  edge  of  the  bowel  is  to  be  attached  to  the 
skin  ;  it  is  then  made  to  transfix  the  bowel  and  brought  out  at 
the  opposite  edge  of  the  abdominal  incision  at  a  corresponding 
point.  After  two  such  sutures  have  been  passed  and  intrusted 
to  an  assistant,  the  bowel  may  be  opened  by  a  longitudinal  in- 
cision, about  three-quarters  of  an  inch  in  length,  over  the  sut- 


MALFORMATIONS    OF   THE    RECTUM    AND    ANUS.  51 

ures  which  pass  across  its  calibre.  The  middle  of  each  suture  is 
then  drawn  out  of  the  bowel  and  divided.  In  this  way  four 
sutures  will  be  in  place,  and  after  they  have  been  secured  one 
may  be  inserted  at  each  end  of  the  wound  in  the  bowel,  and  as 
many  more  along  the  sides  as  may  be  necessary  for  perfect  co- 
aptation.    The  sutures  should  be  of  strong  silk. 

Dr.  Lund '  has  invented  the  needles  and  blunt  hook  shown 
in  Fig.  11,  for  facilitating  the  passing  of  the  sutures  in  this 
operation. 

The  immediate  danger  in  the  operation  of  lumbar  colotomy 
is  that  the  peritoneum  may  be  opened  and  death  result  from 
.peritonitis,  due  not  so  much  perhaps  to  the  incision  in  the 
serous  sac  as  to  the  escape  of  fluids  into  its  cavity.  It  has  also 
happened  to  good  operators  to  open  a  coil  of  small  intestine  in- 


Fig.  11. — Needles  for  passing  sutures  in  the  operation  of  colotomy.     Blunt  hook  for  drawing 
suture  from  within  the  bowel. 

stead  of  the  colon  ;  or,  by  missing  the  latter  at  first  on  account 
of  some  change  in  its  position,  to  become  confused  in  the  sub- 
sequent search  and  fail  utterly  in  finding  the  desired  part. 
Both  of  these  most  common  accidents  are  best  avoided  by  a 
close  adherence  to  the  rules  which  have  been  given. 

The  list  of  mishaps  in  connection  with  this  operation  is  a 
long  and  curious  one.  The  wound  is  deep,  and  it  is  more  than 
probable  that  in  many  cases  the  accident  which  the  operation  is 
especially  intended  to  avoid,  and  the  avoidance  of  which  is  the 
one  point  in  favor  of  the  lumbar  over  the  inguinal  incision — a 
wound  of  the  peritoneum — is  not  avoided.  The  portion  of  the 
descending  colon  not  covered  by  peritoneum  varies  greatly  in 
extent  in  different  cases,  and  during  the  operation  there  is  no 
way  of  determining  whether  the  serous  coat  is  or  is  not  under 
the  knife.  The  kidney  has  more  than  once  been  wounded  at 
the  bottom  of  the  incision,3  and  as  good  an  operator  as  Alling- 

'  Lancet,  April  7,  1883.  =  Bryant.  Amussat. 


52  DISEASES    OF    THE    RECTUM    AND    ANUS. 

ham  '  confesses  to  having  opened  the  duodenum  where  it  em- 
braces the  head  of  the  pancreas,  in  an  attempt  to  find  the  colon 
on  the  right  side.  In  children  the  peritoneal  investment  is  more 
complete  than  in  adults,  and  the  operation  is  contra-indicated 
both  on  this  account  and  because  of  the  greater  movability  of 
the  intestine.  In  one  hundred  and  thirty-four  autopsies  on 
children  of  less  than  two  weeks  of  age,  Giraldis  found  the  sig- 
moid flexure  on  the  left  side  in  114  ;  Curling  in  100  found  it  so 
located  in  85  ;  and  Bourcart  in  117  out  of  150.2 

Inguinal  colotomy  is  especially  indicated  in  treating  imper- 
forate anus  in  children,  in  whom  the  mesocolon  is  so  lax  that 
the  sigmoid  flexure  may  wander  even  across  the  aorta  into  the 
opposite  flank.  He  who  attempts  the  extra-peritoneal  operation 
in  a  child  may  consider  himself  fortunate  if  he  finds  the  desired 
point  at  all ;  and  when  found  it  is  so  completely  surrounded  by 
peritoneum  as  to  render  a  wound  of  the  sac  almost  a  certainty. 
The  operation  in  the  groin  too  is  easier  of  performance,  and 
when  successful  the  resulting  anus  is  more  easily  cared  for  by 
the  patient.  These  facts,  together  with  the  decreasing  fear  of 
incising  the  peritoneum,  have  led  some  surgeons  to  advocate 
this  operation  not  only  in  cases  of  adults  where  disease  has  en- 
croached upon  the  sigmoid  flexure,  where  it  is  particularly  in- 
dicated, but  in  all  cases  for  which  the  lumbar  incision  is  gener- 
ally chosen.  The  inguinal  operation  is  in  great  favor  among 
the  French,  the  lumbar  among  the  English.3 

An  incision  about  two  inches  and  a  half  long  is  made  in  the 
left  groin  parallel  with  Poupart's  ligament,  about  half  an  inch 
above  it,  and  well  toward  the  lateral  wall  of  the  abdomen — so 
far  that  the  epigastric  artery  should  not  be  seen  in  the  opera- 
tion. This  incision  is  carried  down  to  the  peritoneum,  each 
successive  layer  being  divided  on  a  director,  as  is  usual  in  oper- 
ations on  this  part.  Before  the  peritoneum  is  opened  all  haem- 
orrhage from  the  wound  should  be  stopped  and  the  cut  rendered 
as  dry  and  clean  as  possible.  The  peritoneum  is  then  pinched 
up  with  forceps  and  nicked,  a  director  is  introduced,  and  the 

'Op.  cit.,  p.  230.  'Guyon  :  Diet.  Encyc  des  Sci.  Med.     Paris,  1863. 

3  For  discussion  as  to  the  relative  merits  of  the  two  operations  the  reader  is  re- 
ferred to  the  following  articles  :  Dupuytren,  Diet,  en  30  vols.,  Art.  Anus  Artificiel ; 
Videl  de  Cassis,  These  de  ('onconrs,  1812;  Guyon,  Diet.  Encyc.  des  Sci.  Mt'-d.,  Paris, 
L863  ;  Giraldfcs,  Nouv.  Diet,  de  Med  et  de  Chir.  prat.,  t.  ii.,  p.  633  ;  Robert,  Bull,  de 
l'acad.  Roy.  de  Mod.,  t.  xxi.,  p.  981, 


MALFORMATIONS    OF   THE    RECTUM    AND    ANUS.  53 

opening  enlarged  to  the  extent  of  an  inch  and  a  half.  The  de- 
scending colon  should  be  in  view  immediately  below  the  wound, 
and  is  recognized  by  the  usual  sign.  When  such  is  the  case 
the  subsequent  steps  of  the  operation  are  comparatively  sim- 
ple ;  the  incision  into  its  wall  and  its  union  to  the  abdominal 
wound  being  accomplished  in  the  same  manner  as  already  de- 
scribed in  the  lumbar  operation.  But  when  such  is  not  the 
case  the  bowel  must  be  searched  for,  and  it  may  be  necessary 
to  enlarge  the  original  incision.  The  operation  may  be  modified 
with  advantage  by  stitching  the  parietal  and  visceral  layers  of 
the  peritoneum  together  with  sutures  passing  down  to  the  sub- 
mucous layer  of  the  bowel,  but  not  into  its  calibre.  The  wound 
ma}'-  then  be  covered,  and  the  opening  into  the  bowel  delayed 
for  six  or  eight  hours  for  adhesions  to  occur. 

The  following  case  from  Molliere  '  illustrates  very  well  the 
difficulties  which  may  attend  the  operation  in  an  adult  under 
such  circumstances. 

"An  unfortunate  woman  was  admitted  to  the  hospital  at 
night  with  symptoms  of  acute  intestinal  obstruction.  The  ab- 
domen was  greatly  distended,  but  she  asserted  that  it  had  been 
much  increased  in  size  for  a  long  time  previous.  As  death  was 
imminent  and  punctures  into  the  intestine  through  the  abdom- 
inal wall  gave  no  relief,  inguinal  colotomy  was  decided  upon. 
Scarcely  was  the  incision  made  into  the  peritoneum  before  a 
quantity  of  ascitic  fluid  escaped,  and  an  enormous,  white,  shiny, 
aponeurotic-looking  tumor  made  its  appearance.  This  tumor 
was  somewhat  movable.  The  operator,  believing  that  he  was 
dealing  with  an  ovarian  cyst,  and  despairing  of  reaching  the 
colon,  made  an  incision  into  the  small  intestine  from  which  es- 
caped a  large  quantity  of  faeces.  The  autopsy  demonstrated 
later  that  this  tumor  was  itself  the  colon,  greatly  distended 
above  a  contraction  caused  by  cicatricial  bands  in  the  pelvis. 
The  patient  had  succumbed  to  a  general  tubercular  peritonitis.'' 

7.  Attempts  at  Establishing  an  Anus  in  the  Anal  Region 
after  the  Performance  of  Colotomy  are  Attended  with  Great 
Danger,  and  are  Generally  Unsuccessful. — Perhaps  the  best 
authority  on  this  point  is  embraced  in  the  experience  of  Mr. 
Owen.2    In  two  cases  in  which  after  an  interval  of  three  months 


Op.  cit. 

Surgery  of  Childhood.     Brit.  Med.  Jour.,  February  21,  28  ;  March  6,  1880. 


54  DISEASES    OF   THE    RECTUM    AND    ANUS. 

lie  attempted  to  establish  an  anus  in  the  natural  position,  the 
end  was  a  fatal  peritonitis  due  to  the  fact  that  the  rectal  pouch 
was  completely  covered  with  peritoneum.  Dr.  Byrd  '  has  more 
recently  reported  a  case  in  which  the  operation  was  successful. 
The  bowel  ended  in  this  case  in  a  sort  of  cul-de-sac  with  an 
appendix,  and  the  operation  is  described  as  follows  :  "  By  pass- 
ing my  finger  into  the  bowel  through  the  wound,  I  found  that 
the  calibre  of  the  bowel  easily  permitted  its  passage  for  about 
three  inches,  when  it  suddenly  narrowed,  and  from  that  point 
downward  it  resembled  the  appendix  vermiformis.  Into  this 
narrowed  portion  was  passed  a  small  sound  used  for  searching 
for  stone  in  infants,  and  the  end  of  it  worked  downward  in  the 
narrowed  bowel  toward  the  anus. 

To  more  easily  meet  the  sound  from  below,  an  incision  was 
made  about  two  inches  deep,  up  from  the  anus  and  back  to  the 
coccyx,  large  enough  to  permit  the  passage  of  the  index  finger. 
The  sound  was  carried  along  until  it  could  be  felt  only  about 
one-eighth  of  an  inch  from  the  tip  of  the  ringer  passed  from 
below,  when  it  would  pass  no  further  with  ease.  Force  enough 
was  then  used  to  pass  the  sound  through  the  intervening  space, 
and  the  point  was  brought  out  at  the  anus.  To  the  point  of  the 
sound  a  stout  thread,  running  through  a  No.  10  Jacques  cathe- 
ter, was  attached  with  a  reef  knot,  and  the  sound  was  retracted, 
bringing  the  catheter  with  it.  One  end  protruded  from  the 
anus,  and  the  other  from  the  artificial  anus.  To  the  end  pro- 
truding from  the  artificial  opening,  a  compress  was  tied,  and 
by  placing  a  bit  of  rubber  dam  under  the  compress  and  drawing 
the  catheter  down,  extrusion  of  the  bowel  was  prevented,  and 
some  control  was  exerted  over  the  faeces.  The  child  was  very 
much  prostrated  by  the  shock  of  this  operation,  but,  by  the 
second  day,  he  had  fully  recovered." 

This  plan  of  treatment  was  continued  as  follows  :  The  au- 
thor took  "  a  piece  of  soft  rubber  tubing  about  as  large  around 
as  my  little  finger  and  one  foot  long.  By  tucking  half  an  inch 
of  one  end  up  into  the.  tube,  it  made  a  bulbous  end  somewhat 
larger  than  the  rest  of  the  tube  ;  this  end  I  fastened  to  the  ca- 
theter, where  it  came  out  at  the  side,  with  a  stout  flax  thread, 
and  drew  it  down  into  the  bowel  by  retracting  the  catheter. 


1  Lumbo-Colotomy  in  the  New-Born  for  Relief  of  Imperforate  Rectum.     Read  be- 
fore the  Tri-State  Med.  Soc,  St.  Louie,  October  25,  1881.     (Reprint.) 


MALFORMATIONS    OF   THE    RECTUM    AND    ANUS.  55 

As  I  expected  and  desired,  it  caught  against  the  shoulder  of  the 
narrowed  bowel,  and  by  traction  upon  the  catheter,  the  mucous 
membrane  was  brought  down  in  a  fold  in  front  of  the  bulb,  and 
covered  the  space  that  otherwise  would  have  been  filled  with 
cicatricial  tissue.  To-day  (about  one  month  after  the  introduc- 
tion of  the  rubber  tube)  I  removed  the  tube,  and  find  my  little 
finger  passes  readily  up  the  opening,  which  is  covered  through- 
out with  mucous  membrane." 

Unfortunately  the  history  of  this  case  ends  at  this  point,  the 
author  expressing  the  hope  that  the  artificial  anus  would  close 
"  without  further  operative  interference,  except  the  wearing  of 
a  well-adjusted  pad,"  and  being  prepared  to  perform  a  further 
operation  for  its  closure  should  it  prove  to  be  necessary. 

Kronlein1  also  reports  a  successful  case  of  this  operation. 
A  child  six  days  old  had  had  no  evacuation  of  the  bowels  since 
its  birth.  The  anus  was  extremely  narrow  and  ended  in  a  pouch 
2.5  ctm.  long.  An  attempt  to  reach  the  rectum  by  an  incision 
through  this  pouch  resulted  only  in  opening  the  peritoneum, 
as  was  shown  by  a  free  discharge  of  peritoneal  fluid.  The 
bowel  was  then  opened  in  the  left  groin,  and  the  child  lived 
and  thrived.  When  the  child  had  reached  the  age  of  seven 
months,  the  rectal  pouch  could  be  distinguished,  and  the  orig- 
inal operation  was  again  attempted,  and  the  rectal  pouch  suc- 
cessfully united  with  the  lower  one.  At  the  close  of  the  re- 
port, a  stricture  existed  at  the  place  of  union,  but  the  larger 
part  of  the  faeces  were  already  evacuated  by  the  perineal  open- 
ing. 

The  attempt  to  re-establish  an  anus  in  the  anal  region  origin- 
ated with  Demarquay,  and  involves,  if  it  be  successful,  a  subse- 
quent attempt  to  close  the  artificial  opening.  This  is  an  opera- 
tion of  still  greater  danger  and  one  seldom  successful.  The 
difficulties  consist  in  re-establishing  the  calibre  of  the  bowel  at 
the  point  where  it  is  partially  occluded  by  the  formation  of  the 
artificial  opening,  and  in  subsequently  closing  this  opening  by  a 
plastic  operation.  The  danger  is  of  fatal  peritonitis.  It  is  well 
known  that  in  cases  of  colotomy,  the  side  of  the  bowel  opposite 
the  opening  becomes  sharply  bent  upon  itself,  as  shown  in  Figs. 
12  and  13.  The  septum  thus  formed  is  composed  of  two  layers, 
each  consisting  of  the  whole  thickness  of  the  intestinal  wall, 

Berlin.  Klin.  Woch.,  1879,  No.  34-35. 


56  DISEASES    OF    THE    RECTUM    AND    ANUS. 

and  it  must  be  destroyed  before  the  lumen  can  be  re-established 
and  the  opening  safely  closed.  Dupuytren's '  original  opera- 
tion consists  first  in  compressing  this  valve  by  an  instrument  in- 
vented by  himself,  the  action  of  which  is  shown  in  Fig.  14. 

This  was  applied  and  tightened  so  as  at  once  to  cause  the 
death  of  the  included  portion.     The  subsequent  steps  in  the 


3  $ 

Fig.  12.  Fig.  13. 

Condition  of  the  Bowel  after  Colotomy,  showing  Septum  and  course  of  Faeces.    (Packard.) 

operation  consisted  in  closing  the  artificial  opening.  His  expe- 
rience extended  over  41  cases,  21  of  which  were  done  by  himself 
and  20  by  others.  Three  cases  were  fatal.  Of  the  remaining  38 
the  operation  was  unsuccessful  in  8,  and  successful  in  29  in 
periods  varying  from  two  to  six  months.  It  is  but  proper  to  say 
that  considerable  doubt  exists  as  to  the  reliability  of  this  very 
favorable  showing. 

Since  his  time,  the  operation  of  Dupuy  tren  has  been  modified 
in  various  ways  by  different  surgeons.  Barker2  has  recently  re- 
ported a  successful  operation  after  a  plan  of  his  own,  the  essen- 


Fig.  14. — Enterotome  of  Dupuytren  in  Position.    (Packard. ) 

tial  feature  of  which  consists  in  introducing  into  the  bowel 
through  the  artificial  anus,  after  the  projecting  spur  of  the 
bowel  has  been  removed  in  the  usual  way,  a  thin  and  flexible 
strip  of  rubber  about  one  inch  and  a  half  long  by  five-eighths 


1  Lecons  Orales  de  Clin.  Chirurgicale.     Paris,  1839,  t.  iv.,  p.  1. 
1  A  Suggested  Improvement  in  Dupuytren's  Operation  for  Artificial  Anus,  and  a 
Successful  Case  Treated  by  it.     Lancet,  December  18,  1880. 


MALFORMATIONS    OF    THE    RECTUM    AND    ANUS.  57 

of  an  inch  broad,  in  such  a  manner  as  to  lap  up  against  the  in- 
ternal orifice  ;  and  to  secure  this  in  position  by  a  single  wire 
stitch  at  each  end  passed  through  the  abdominal  wall.  The 
object  is  to  allow  the  rubber  to  remain  till  the  fistula  is  closed 
by  paring  and  suturing  its  edges,  and  then  by  cutting  the  wires 
to  allow  it  to  pass  down  the  bowel.  In  the  case  recorded,  the 
rubber  answered  the  purpose  of  preventing  the  escape  of  faeces 
very  perfectly  for  the  first  few  days,  after  which  there  began  to 
be  leakage,  and  it  was  removed.  The  fistula,  however,  went  on 
to  complete  closure. 

The  most  successful  operation,  however,  for  the  closure  of 
an  artificial  anus  would  seem  to  be  the  one  performed  by  Dr. 
Byrd  and  described  by  him  as  follows.1 

"The  eperon  was  destroyed  with  an  enterotome  made  of 
steel  wire  bent  into  the  shape  of  a  pair  of  tongues,  with  the 
blades  having  fenestrated  openings  that  more  tissue  could  be 
enclosed  within  their  bite.  This  was  applied  by  passing  a  blade 
into  each  end  of  the  bowel  about  two  inches.  The  spring  of  the 
instrument  caused  sufficient  inflammation  to  secure  surround- 
ing adhesions  to  a  certainty,  and  the  pressure  being  reinforced 
in  three  days  with  a  strong  India  rubber  band  over  the  blades, 
an  ulcerative  process  ensued  which  caused  the  eperon  between 
the  blades  to  disappear." 

"The  eperon  having  been  destroyed  I  operated  for  the 
closure  of  the  artificial  anus  in  the  following  manner  :  The  skin 
on  either  side  of  the  opening  was  caught  up  in  a  fold  in  such  a 
manner  that  the  top  of  the  folds  met  easily  over  the  opening  in 
the  bowel ;  an  incision  along  the  top  of  these  folds,  which  was 
about  three-quarters  of  an  inch  from  the  opening  in  the  bowel, 
was  then  made  through  the  skin  and  superficial  fascia,  and  ex- 
tended so  as  to  form  an  ellipse  enclosing  the  opening.  That 
portion  of  the  skin  next  the  opening  was  then  dissected  up 
from  the  outer  side,  leaving  it  attached  at  the  inner  side  to  the 
opening  in  the  bowel  ;  it  was  then  inverted,  and  turned  into  the 
bowel.  This  procedure  brought  the  raw  surfaces  in  apposition, 
and  threw  skin  into  the  bowel  so  as  to  form  a  continuation  of 
the  mucous  membrane.  The  skin  on  either  side  of  this  elliptical 
raw  surface  was  now  brought   together  by  passing  two  stay 


1  Excisions  of  Portions  of  the  Alimentary  Canal  Covered  by  Peritoneum,  by  Wil- 
liam A.  Byrd.  M.  D.,  Quincy,  111.     Reprint  from  Trans,  of  the  Amer.  Med.  Association. 


58  DISEASES    OF    THE    RECTUM    AND    ANUS. 

sutures,  with  a  shot  and  shield,  back  about  an  inch  from  the 
cut  edges,  and  making  traction.  This  brought  the  edges  to- 
gether and  made  them  rise  from  the  abdomen  like  an  inverted 
V.  Where  the  skin  met  at  the  apex  of  the  V,  it  was  fastened 
with  catgut  suture.  The  portion  of  skin  in  the  intestine  was 
shaped  like  a  V,  and  that  outside  had  its  apex  immediately 
above  the  apex  of  the  lower  one.  By  this  procedure  fully  an 
inch  and  a  half  of  raw  surface  was  brought  in  contact  over  the 
opening  in  the  bowel,  thus  almost  insuring  sufficient  adhesion, 
while  the  V  raw  surfaces  of  the  skin  that  was  inverted  into  the 
bowel  acted  as  a  valve,  and  were  held  in  apposition  by  the  pres- 
sure of  the  contents  of  the  bowel.  There  was  some  oozing  of 
faecal  matter,  for  a  few  days  after  the  operation,  from  the 
corners  of  the  wound,  but  these  slight  openings  closed  readily 
by  applying  pressure  with  a  sponge,  and  she  is  now  in  excellent 
health,  perfectly  recovered." 


CHAPTER   III. 

GENERAL    RULES    REGARDING   EXAMINATION,  DIAGNOSIS,  AND   OPERA- 
TION. 

Necessity  for  Physical  Examination. — Questions  which  may  Lead  to  Diagnosis. — How 
to  make  Examination. — Table. — Lamp. — Instrument  Case. — Position  of  Patient. 
— Necessity  for  Enema  before  Examination. — Apparatus  for  Injections. — What 
may  be  Learned  by  Simple  Inspection. — Rectal  Touch. — What  may  be  Discovered 
by  it. — Bougies;  Varieties;  Author's  Bougies. — Rectal  Specula:  Helmuth's  ; 
Author's;  Fenestrated;  Bivalve;  Objections. — Colonoscopy  —  Stretching  the 
Sphincter  ;  Proper  Method  of  Performing  the  Operation  ;  Results.  — Difficulties  of 
Diagnosis  of  Disease  high  up  in  the  Rectum. — Manual  Examination. — What  may 
be  Learned  by  this  Method. — Preparation  of  Patient  for  Operation. — Assistants. — 
Primary  Anaesthesia. — Thermo-Cautery.— Haemorrhage. — Rules  for  Controlling 
Haemorrhage. — Cold.— Styptics. — Packing  the  Rectum. — Treatment  after  Opera- 
tion.— Dressings. — Necessity  for  Rest. — Retention  of  Urine. — Case  of  Fatal  Re- 
tention. 

To  one  who  has  been  trained  in  the  habit  of  making  a  diagnosis 
before  undertaking  treatment  it  seems  superfluous  to  insist 
upon  the  necessity  of  a  physical  examination  in  cases  of  rectal 
disease.  The  majority  of  patients  who  seek  advice  for  this  class 
of  troubles  come  to  the  surgeon  with  the  diagnosis  of  piles  or 
fistula  ready  at  hand,  and,  I  am  sorry  to  say,  many  of  them 
come  with  the  authority  of  some  physician  for  that  diagnosis, 
in  whom,  nevertheless,  the  merest  inspection  is  sufficient  to  prove 
the  existence  of  much  more  serious,  and  often  of  incurable, 
disease.  This  is  not  due  to  ignorance,  but  to  carelessness,  to 
too  great  faith  in  the  statements  of  the  sufferers,  and  often  to  a 
false  modesty  on  the  part  of  the  practitioner  which  leads  him 
to  accept  such  statements  in  lieu  of  a  thorough  examination. 

The  following  case  illustrates  many  points  in  rectal  diagnosis 
and  may  be  as  useful  to  others  as  it  was  to  myself. 

Case. — Illustrating  Difficulty  in  Diagnosis. — A  young 
man  appearing  in  perfect  health  was  sent  to  me  by  Dr.  ~N.  M. 
Shaffer,  of  New  York,  for  rectal  trouble.  He  gave  me  a  history 
of  constant  discharge  from  the  bowel  and  of  some  pain  after 


60  DISEASES    OF   THE    RECTUM   AND    ANUS. 

defecation,  but  the  discharge  was  his  chief  trouble.  On  exam- 
ination I  discovered  a  fistula,  but  such  an  insignificant  subcu- 
taneous affair  that  I  divided  it  on  the  spot,  recommended  a 
day's  rest,  and  assured  him  that  he  would  be  entirely  well  in  a 
week  without  further  treatment.  The  fistula  was  well  in  a 
week,  but  the  man  was  not.  He  still  complained  of  discharge 
and  some  pain,  though  less  than  before.  I  made  a  second  and 
more  careful  examination,  and  discovered  a  perfectly  well- 
marked  fissure  just  above  the  external  sphincter.  Once  more  I 
assured  him  that  he  could  easily  be  cured,  and  I  divided  the 
base  of  the  ulcer  with  a  bistoury.  The '  operation  was  thor- 
oughly done,  for  I  was  a  little  chagrined  at  my  former  careless- 
ness and  wished  to  make  sure  of  the  cure.  The  operation  was 
not  followed  by  the  slightest  relief,  and  six  weeks  were  passed 
in  the  vain  hope  of  a  cure.  I  then  did  what  should  have  been 
done  in  the  first  place,  and  set  myself  deliberately  to  make  a 
complete  diagnosis.  I  etherized  the  patient,  dilated  his  sphinc- 
ter, and  made  a  thorough  examination  with  artificial  light.  The 
fissure  could  be  plainly  seen,  and  above  it  there  was  a  polypus 
of  considerable  size,  which  by  its  mobility  had  escaped  me  in 
the  former  examination,  and  by  its  contact  with  the  surface  of 
the  sore  had  prevented  a  cure.  This  was  removed,  but  the  man 
was  not  yet  cured.  The  pain  had  all  disappeared,  but  the  dis- 
charge from  the  bowel  still  remained  in  diminished  quantity.  I 
was  about  to  despair,  when  he  mentioned  in  the  most  casual 
way  that  he  had  had  a  good  deal  of  itching  at  the  anus  for 
some  time  back,  and  an  examination  revealed  a  moist  eczema 
which  furnished  the  discharge.  The  skin  disease  had  been  there 
from  the  first,  but  as  the  man  had  asserted  that  it  never  troubled 
him,  I  had  paid  little  attention  to  it.  This  was  easily  cured, 
and  I  ultimately  had  the  satisfaction  of  seeing  my  patient  well. 
Here  then  was  rather  an  unusual  combination  of  troubles — a 
fistula,  a  fissure,  a  polypus,  and  eczema,  and  each  one  sufficient 
in  itself  to  account  for  all  the  symptoms  of  which  the  patient 
complained.  But  all  should  have  Deen  discovered  at  the  first 
examination,  and  the  man  should  have  been  cured  by  one  oper- 
ation instead  of  three. 

The  symptomatology  alone  may  be  of  great  value  in  the 
diagnosis  of  rectal  disease  ;  it  is  almost  never  sufficient  in  itself 
ft  >r  a  diagnosis.  There  is  a  train  of  symptoms  common  to  almost 
all  diseases  of  this  part,  and  which  infallibly  points  to  trouble 


GENEKAL    RULES    REGARDING    EXAMINATION",    ETC.  61 

of  some  kind,  but  they  do  not  tell  what  that  trouble  is.  The 
pain  of  a  fissure  is,  perhaps,  diagnostic  of  the  fissure,  but  it 
does  not  tell  what  troubles  may  be  associated  with  the  fissure  ; 
and  so  it  is  in  every  other  affection.  For  this  reason  the  practi- 
tioner who  attempts  to  treat  a  case  of  disease  of  the  rectum 
without  first  making  a  direct  examination,  uselessly  risks  his 
reputation  as  a  diagnostician,  and  in  my  own  practice  I  am 
guided  by  the  simple  rule  that  patients,  male  or  female,  who 
have  not  yet  come  to  the  point  which  makes  them  willing  to 
submit  to  an  examination,  have  not  yet  reached  a  point  which 
admits  of  treatment.  An  examination,  especially  in  women,  is 
sometimes,  though  not  often,  difficult  to  obtain,  and  the  dread 
of  it  keeps  many  sufferers  from  seeking  relief  ;  but  still  the  rule 
I  have  laid  down  is  the  only  safe  one,  and  the  surgeon  who 
allows  himself  to  be  persuaded  into  "recommending  something 
for  piles,"  will  sooner  or  later  have  a  mistake  in  diagnosis  laid 
to  his  charge,  nor  will  the  fact  that  he  was  moved  by  considera- 
tion for  the  patient's  sensibilities  save  him  from  blame. 

I  have  often  found  that  the  best  way  to  secure  an  examina- 
tion in  women  who  otherwise  could  not  be  brought  to  consent  to 
it,  was  to  resort  to  ether,  with  the  understanding  that  whatever 
surgical  procedure  was  thought  advisable  should  be  performed 
at  the  same  time.  In  this  way  a  patient's  sensibilities  may 
often  be  spared,  while  both  diagnosis  and  treatment  are  included 
in  one  examination. 

Before,  however,  proceeding  to  make  the  physical  examina- 
tion which  is  inevitable,  certain  questions  and  answers  may  give 
the  surgeon  a  pretty  clear  idea  of  what  he  is  about  to  find.  It 
is  generally  a  good  plan  to  allow  an  intelligent  patient  to  tell 
his  or  her  own  history,  and  then  to  supplement  it  with  appro- 
priate questions  as  to  the  length  of  time  since  the  trouble 
began  ;  the  character  of  pain  when  present,  whether  constant  or 
intermittent,  and  increased  by  defecation  ;  whether  it  comes 
with  the  stool,  immediately  or  some  time  after,  and  its  duration. 
The  question  of  discharge  should  also  be  inquired  into,  its 
quantity  and  character,  whether  blood,  pus  or  mucous  ;  also 
whether  there  is  any  protrusion  of  any  kind,  and  its  character. 
The  answers  to  these  questions,  and  to  those  which  relate  to  the 
presence  or  absence  of  diarrhoea,  constipation,  and  incontinence, 
will  generally  give  the  surgeon  a  fair  idea  of  the  nature  of  the 
case  before  him. 


62 


DISEASES    OF    THE    BECTUH    ABB    ANUS. 


How.  then,  to  proceed  to  make  a  rectal  examination  which 
shall  be  at  the  same  time  thorough  and  as  free  from  pain  as 


Fig    1*5.—  The  tame  ready  for  use. 


bid    Two  things  are  necessary  above  all  others,  a  good 
bed  or  table,  and  a  good  light.     For   a  table,  a  strong  four- 


GENERAL    RULES    REGARDING    EXAMINATION,    ETC. 


C: 


legged  one.  upholstered  with  hair  and  leather,  answers  every 
purpose.  It  should  be  hard,  without  springs,  and  about  thirty 
inches  in  height.  In  place  of  this,  any  of  the  examining  tables 
of  the  gynaecologists  may  be  used.  In  my  own  office,  I  use  the 
Archer  Gynaecological  Chair,  shown  closed  and  open  in  Fig.  15 
and  Fig.  16. 

Its  great  advantage  is  that,  when  not  in  use,  it  answers  as  an 
ordinary  piece  of  furniture,  and  when  raised  it  provides  a  firm. 


Fig.  IT.— Lamp  for  Rectal  Examination.1 

Lard,  operating  table  of  convenient  height.  Either  natural  or 
artificial  light  may  be  used,  but  the  latter  is  on  some  accounts 
preferable,  being  always  at  command,  and  easily  thrown  up 
the  bowel  or  concentrated  upon  a  particular  point.  The  lamp 
which  I  have  found  most  convenient  is  a  modification  of  To- 
bold*  s  laryngoscope,  which  has  for  many  years  been  in  use 
by  Dr.  Sass,  of  New  York,  and  is  shown  in  Fig.  17.    It  is  not 


1  Made  by  A.  Keune  <fc  Son,  New  Haven  Railroad  Building,  Franklin  Street,  New 
York. 


64  DISEASES    OF    THE    RECTUM    ABB    AKUS. 

only  a  very  powerful  lamp,  but  a  very  elegant  piece  of  mech- 
anism. 

The  instruments  necessary  are  specula  of  various  forms, 
bougies,  a  Davidson's  syringe,  ointment,  cotton,  sponge-holders 
(Fig.  18) ;  brushes  (Fig.  19) ;  a  cup  for  fusing  nitrate  of  silver 


Fig.  IS. — Sponge  Holder. 

(Pig.  20) :  an  applicator,  of  some  metal  easily  bent,  around  the 
end  of  which  cotton  may  be  twisted  (Pig.  21 1 ;  towels,  basins, 
etc.  ;  and  these  should  all  be  placed  within  easy  reach  of  the 
hand.  In  the  matter  of  probes  almost  every  variety  is  useful, 
from  the  hard  rubber  uterine  probe  to  the  finest  wire  of  pure 


Fig.  19.— Brush  on  Flexible  Handle. 


silver  ;  and  directors  also'  should  be  of  many  sizes.  A  conve- 
nient case  for  these  things,  and  for  other  surgical  instruments, 
which  is  intended  to  stand  on  the  floor  by  the  side  of  the  table 
or  bed,  is  represented  in  Fig.  22. 

The  position  in  which  the  patient  should  be  placed  is  a  mat- 


jjj*u-**.*"%r>r- 


Fig.  20.— Cup  for  Fusing  Nitrate  of  Silver. 

ter  of  some  importance.  For  mere  inspection  of  the  anus  and 
%  surrounding  parts,  the  dorsal  decubitus  answers  every  purpose, 
and  a  digital  examination  of  the  rectum  may  be  made  either  in 
this  posture  or  with  the  patient  on  the  side.  For  a  speculum 
examination  or  the  passage  of  a  bougie,  the  patient  should  be 


Tfij"-     ■■-'/»,<*>; 


Fig.  21 . —Applicator. 


placed  on  the  side,  with  the  buttocks  well  elevated,  the  thigh 
which  is  uppermost  strongly  flexed  on  the  abdomen,  and  the 
breast  resting  on  the  table.  In  this  way  the  weight  of  the  ab- 
dominal contents  falls  upon  the  front  wall  of  the  abdomen,  and 
not  upon  the  pelvis,  and  the  lumen  of  the  bowel  is  not  so  firmly 


GENERAL    RULES    REGARDING    EXAMINATION",    ETC.  65 

closed,  nor  is  the  mucous  membrane  so  firmly  forced  into  the 
end  of  the  speculum. 

Before  commencing  an  examination,  the  bowel  should  be 
emptied,  either  by  the  natural  effort  of  the  patient  or  by  an 
enema,  and  for  this  reason  a  water-closet  in  connection  with  the 
examining-room  is  indispensable  to  the  practitioner  in  rectal  dis- 
ease. In  this  way  the  patient  may  come  directly  from  the  closet 
to  the  table  with  the  parts  in  the  best  condition  for  inspection; 
and  great  additional  confidence  is  acquired,  especially  by  women, 
that  the  examiner's  frequent  reiteration  to  "bear  down"  will 
not  be  followed  by  untoward  consequences.  The  point  may 
seem  trivial,  but  the  fear  of  an  accident  will  frequently,  in 


Fig.  22. — Case  for  Rectal  Instruments,  with  sliding  cover  A  A. 

women,  result  in  a  firmly  closed  sphincter,  which  no  word  of 
the  surgeon  can  overcome,  and  a  thorough  examination  cannot 
be  made  while  the  rectal  pouch  is  filled  with  faeces.  This  is  not 
merely  a  thing  to  be  observed  for  the  cleanliness  of  the  exam- 
iner, for  the  act  of  defecation  will  bring  internal  hemorrhoids 
and  prolapse  to  the  light,  and  may  greatly  assist  in  the  diagno- 
sis of  other  maladies.  In  examination  with  a  speculum,  it  is 
indispensable  to  cleanliness. 

For  facilitating  this  part  of  the  examination  I  have  arranged 
the  injecting  apparatus  shown  in  Fig.  23.    The  water  in  the  res- 
ervoir can  be  made  of  any  temperature  by  means  of  the  two 
stop-cocks,  the  force  can  be  regulated  by  raising  or  lowering  it ; 
5 


M 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


it  is  always  ready  for  use,  and  where  a  practitioner  has  much  of 
this  work  to  do  it  will  be  found  a  great  improvement  upon  a 
Davidson's  syringe.  It  also  answers  for  cleansing  wounds,  or 
for  any  other  purpose  for  which  a  syringe  is  ordinarily  used.  It 
should  be  provided  with  a  number  of  tips,  one  for  an  ordinary 


Fig.  23. — Apparatus  for  Injections. 


enema,  one  which  will  fit  closely  into  a  hollow,  rectal  bougie, 
and  one  very  line  one,  preferably  of  glass,  which  can  be  intro- 
duced into  the  external  opening  of  a  fistula  in  case  it  is  neces- 
sary to  discover  whether  the  latter  communicates  with  the 
bowel.  In  connection  with  this  apparatus  the  hard-rubber  basin 
shown  in  Fig.  24  will  be  found  very  useful.  ; 


GENERAL    RULES    REGARDING    EXAMINATION,    ETC.  67 

A  simple  inspection  of  the  anus  and  adjacent  skin  and  mu- 
cous membrane  is  often  sufficient  for  a  diagnosis,  though  it 
should  never  be  trusted  to  alone.  External  haemorrhoids  and 
internal  ones,  when  brought  down  by  the  use  of  the  closet  or 
enema,  external  fistulas,  ulceration,  skin  diseases,  many  venereal 
affections,  pin-worms,  abscess,  and  fissure,  may  all  be  recog- 
nized in  this  way.  A  glance  at  the  anus,  too,  may  indicate  to 
the  practised  eye  the  existence  of  serious  disease  within  the 
rectum  proper,  for  a  discharge  may  flow  from  it  which  marks 
ulceration  above,  and  it  may  be  relaxed  and  patulous  from 
over-distention    or    partial  destruction   of    the    sphincter.    A 


Pig.  24.— Hard  Rubber  Pus  Basin. 

sunken  condition  of  the  ischio-rectal  fossae,  and  a  retracted 
anus,  surrounded  by  a  profusion  of  soft,  fine  hair,  may  also 
properly  excite  a  suspicion  either  of  grave  rectal  disease  or  of 
some  constitutional  affection  which  is  causing  emaciation. 

By  using  gentle  force  in  pulling  the  anus  open  with  the  fin- 
gers, the  mucous  membrane  may  be  everted  to  a  considerable 
degree,  especially  if  the  patient  can  be  brought  to  assist  by  an 
effort  at  bearing  down.  In  this  way  a  fissure  may  almost  always 
be  brought  into  view  without  the  use  of  a  speculum  of  any  sort, 
and  the  internal  opening  of  the  great  majority  of  fistulae  may 
be  reached,  with  a  good  view  of  the  radiating  folds  and  lacunae. 

Dr.  Storer,1  of  Boston,  has  described  a  method  of  examining 
the  mucous  membrane  just  within  the  anus,  which  is  applicable 
only  in  women  who  have  a  lax  sphincter.  It  consists  in  evert- 
ing the  mucous  membrane  by  pressing  it  out  of  the  anus  by  the 
index  finger  in  the  vagina.     In  a  case  in  which  the  manoeuvre 

1  Lancet,  May  31,  1873. 


68  DISEASES    OF    THE    RECTUM    AND    ANUS. 

can  be  practised  successfully,  and  without  too  much  pain,  a 
small  portion  of  the  anterior  wall  of  the  rectum  may  be  brought 
into  view.  The  pessary  of  Gariel  has  also  been  used  for  the 
same  purpose.  It  consists  of  a  rubber  ball,  which  is  introduced 
empty  into  the  rectal  pouch,  then  inflated  by  means  of  a  tube 
attached  to  it,  and  withdrawn  with  some  force,  the  mucous 
membrane  being  prolapsed  in  front  of  it.  But  neither  of  these 
two  procedures  is  of  any  great  value. 

After  having  examined  the  anus  in  this  way,  the  surgeon 
next  proceeds  to  the  more  difficult  task  of  examining  the  rec- 
tum, an  operation  which  may  be  done  skilfully  and  almost 
painlessly,  or  awkwardly  and  with  great  suffering.  The  rectum 
may  be  explored  either  by  the  touch  alone,  or  by  vision  alone, 
or  by  both  combined.  The  former  is  the  simpler  and  more 
painless  method,  and  with  practice  may  be  made  to  afford  all 
the  information  which  can  be  gained  by  the  two  combined. 

To  practise  the  rectal  touch,  the  nail  of  the  index  finger 
should  be  well  trimmed,  and  the  finger  lubricated  with  some 
tenacious  oil.  Olive  oil  is  much  better  than  vaseline,  the  latter 
being  too  easily  rubbed  off  by  the  sphincter.  The  condition  of 
the  sphincter  muscle  is  first  to  be  noted.  Its  resistance  should 
be  overcome  by  a  slow  and  steady  pressure  with  the  ball  of  the 
finger,  and  not  by  a  sudden  exertion  of  force,  for  such  an  attack 
is  always  met  by  increased  contraction.  The  force  of  the  mus- 
cle will  be  found  to  vary  greatly  in  different  people.  In  the 
aged  or  debilitated  it  is  lax  ;  in  the  strong  and  healthy  it  is  the 
opposite,  and  the  finger  can  scarcely  be  passed  through  it  with- 
out great  pain,  and  sometimes  a  slight  laceration  of  the  tender 
mucous  membrane.  "When  inclined  to  spasmodic  contraction, 
as  it  sometimes  is  in  persons  of  nervous  tendency,  a  satisfactory 
examination  may  be  impossible  without  the  use  of  ether,  on 
account  of  the  pain. 

Unless  an  obstruction  is  encountered,  the  finger  ma}'  be  car- 
ried up  the  bowel  its  full  length,  and  pressed  as  far  as  possible 
beyond  this  point.  Additional  distance  may  be  gained  by  pass- 
ing the  three  remaining  fingers  backward  along  the  inter-gluteal 
groove,  instead  of  closing  them  in  the  palm,  as  is  generally 
done,  and  pressing  the  knuckles  against  the  soft  parts  ;  for  the 
knuckles  prevent  the  fall  passage  of  the  index  finger.  An  inch 
more  may  be  gained  by  having  the  patient  stand  up  and  strain 
down  upon  the  finger  in  the  bowel. 


GENERAL  EULES  EEGAEDING  EXAMINATION,  ETC.     69 

In  this  way  three  and  a  half  or  four  inches  of  the  rectum 
may  be  carefully  explored,  together  with  the  prostate,  the  neck 
of  the  bladder,  the  uterus,  and  the  anterior  surface  of  the  coc- 
cyx and  lower  part  of  the  sacrum.  With  an  exceptionally  long 
finger  it  may  even  be  possible  to  feel  the  vesiculse  seminales  and 
vasa  deferentia.  In  other  words,  all  that  part  of  the  bowel 
which  is  most  subject  to  disease  is  brought  within  reach.  But 
after  this  is  done  the  examiner  may  be  no  wiser  than  before,  for 
to  appreciate  fully  the  condition  of  the  rectum  by  the  sense  of 
touch  alone  requires  a  facility  in  this  method  of  exploration 
which  most  practitioners  never  attain.  In  the  majority  of  cases 
a  digital  examination  will  be  made  to  discover  whether  or  not 
the  patient  is  suffering  from  internal  haemorrhoids,  and  in  the 
majority  of  cases  also  the  examiner  will  be  no  wiser  on  this 
point  after  than  before,  for  a  soft  internal  hsemorrhoid  is  a  diffi- 
cult thing  to  detect  by  the  ringer  alone,  being  readily  mistaken 
for  the  natural  mucous  membrane  of  the  part,  especially  when 
the  latter  is  abundant  and  gathered  into  folds,  as  it  is  apt 
to  be. 

Ulceration  is  another  condition  which  it  is  sometimes  diffi- 
cult to  detect,  especially  when  superficial  and  not  attended  by 
much  induration  ;  and  so  is  the  opening  of  a  blind  internal  fis- 
tula ;  and  yet,  so  well  educated  may  the  finger  become  that 
other  methods  of  examination  may  be  almost  completely  dis- 
carded. To  carry  diagnosis  to  this  point  it  is  first  necessary,  by 
oft  repeated  examinations,  to  become  perfectly  familiar  with 
the  feel  of  the  normal  bowel.  After  this  knowledge  has  been 
gained,  a  gentle  sweeping  of  the  ball  of  the  finger  over  the 
whole  inner  surface  of  the  lower  three  inches  of  the  rectum  will 
detect  any  change  in  it,  however  slight.  I  wish  it  were  possible 
to  describe  plainly  the  different  sensations  which  are  conveyed 
by  the  different  pathological  conditions,  but  this  is  a  thing  each 
practitioner  must  learn  for  himself  by  practice. 

A  stricture  of  small  calibre  cannot  easily  be  mistaken,  though 
one  which  admits  the  ringer  without  constricting  it  may  easily 
be  overlooked.  A  stricture  small  enough  to  engage  the  end  of 
the  index  finger  firmly,  marks  the  limit  of  safe  digital  examina- 
tion, and  the  finger  should  not  be  forced  through  it  for  the  sake 
of  feeling  what  is  above,  for  an  attempt  to  do  this  has  been  fol- 
lowed by  a  fatal  rupture  of  the  bowel.  In  case  of  a  tumor  of 
any  kind,  advantage  may  be  taken  of  conjoined  manipulation 


70 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


through  the  vagina  in  the  female ;  but  these  are  the  troubles 
most  rarely  met  with,  and  most  easily  diagnosticated  when  en- 
countered. The  cervix  or  fundus  of  the  uterus,  when  pressing 
upon  the  bowel,  may  be  distinctly  felt  with  the  finger  in  the 
rectum,  and  may  deceive  the  unwary  into  a  diagnosis  of  a  new 
growth.  The  prostate  may  do  the  same.  The  different  varieties 
of  ulceration  have  each  their  peculiar  and  often  diagnostic  feel. 


Q.TIEMANN  SzCO. 

Fig.  25.— Soft  Rubber  Bougie. 

For  examination  by  the  sense  of  touch  above  the  reach  of 
the  finger,  recourse  may  be  had  to  bougies.  These  are  of  all 
forms,  sizes,  and  materials,  and,  in  general  words,  the  softer 
the  instrument  the  better  it  is  for  examination.  The  black 
rubber  instrument,  with  the  blunt  point  (Fig.  25),  which  may 
readily  be  bent  into  a  circle  in  the  hand,  is  better  than  most 
others  in  the  market,  and  the  same  instrument  comes  with  a 
sharp  point  (Fig.  26),  which  sometimes  answers  a  good  purpose. 
These  instruments  are  made  in  twelve  different  sizes,  and  for 
the  purpose  of  diagnosis  the  medium-sized  is  the  best.  The  old 
fashioned  red,  hard-rubber  bougie  is  unnecessarily  stiff  and 
dangerous,  and  should  be  discarded,  having  no  advantages  over 
the  softer  ones  either  for  the  purpose  of  diagnosis  or  for  that 
of  treatment.     The  bougie  a  boule,  made  of  hard-rubber  with 


G.TJEMANN  &.C0. 

Fig.  20. 


a  flexible  whalebone  handle,  is  a  favorite  instrument  with  many. 
(Fig.  27.) 

For  my  own  use  I  have  had  a  kind  of  bougie  made  by 
Messrs.  Stohlmann,  Pfarre  &  Co.,  which  I  prefer  to  all  others, 
for  the  simple  reason  that  it  is  softer  and  more  flexible  than  any 
in  the  market.  It  is  made  of  the  same  material  as  the  red  soft- 
rubber  catheters,  and  differs  from  them  only  in  size  and  in  the 
thickness  of  its  walls.     (Fig.  28.)    It  is  essentially  the  same  in- 


GENERAL    RULES    REGARDING    EXAMINATION,    ETC. 


71 


strument  as  that  invented  by  Wales,  except  that  it  is  more  flexi- 
ble even  than  his.  With  such  an  instrument  one  is  pretty  cer- 
tain not  to  perforate  the  bowel,  and  for  diagnosis  it  answers 
every  purpose  as  well  as  the  harder  instruments.    The  better 


Fig.  27. 


fitted  a  bougie  is  for  pushing  its  way  through  a  stricture  the 
worse  it  is  for  rectal  exploration.  Every  bougie  intended  for 
exploration  should  be  perforated  so  that  a  stream  of  water  may 
be  injected  through  it. 


Fig.  23. —Red  Soft  Rubber  Bougie. 

These  instruments  are  all  used  for  the  same  purpose — that 
of  feeling  for  a  stricture  located  above  the  reach  of  the  finger  ; 
and  with  any  of  them  the  unpractised  hand  will  generally  de- 
tect an  obstruction  in  the  perfectly  healthy  bowel  at  about  four 


72  DISEASES    OF   THE    RECTUM    AND    ANUS. 

inches  from  the  anus.  I  have  had  patients  in  whom  I  have 
never  been  able  to  pass  any  sort  of  a  bougie  without  first  in- 
jecting the  rectum,  no  matter  what  manoeuvring  I  resorted  to  ; 
and  I  have  seldom  told  a  student  to  pass  a  rectal  bougie  that  he 
did  not  at  once  discover  a  stricture.  To  pass  a  bougie  into  the 
rectum  is  rather  a  more  difficult  operation  than  to  pass  one  into 
the  urethra,  the  triangular  ligament  in  the  latter  being  replaced 
by  the  curves,  the  folds  of  mucous  membrane,  and  the  promon- 
tory of  the  sacrum  in  the  former.  Independent  of  Houston's 
valves  of  mucous  membrane,  it  is  not  improbable  that  a  slight 
degree  of  invagination  of  the  upper  into  the  lower  part  of  the 
rectum  may  often  exist,  and  into  the  sulcus  formed  by  this  con- 
dition the  point  of  the  bougie  may  easily  pass.  For  the  sake 
of  overcoming  these  folds  of  membrane  the  most  minute  direc- 
tions have  been  given  as  to  how  the  bougie  should  be  introduced 
and  gently  urged  along  each  successive  inch  of  the  bowel1  by 
changing  its  direction  and  manipulating  the  handle.  But  such 
rules  are  of  little  value,  for  the  simple  reason  that  the  obstruc- 
tion is  seldom  of  the  same  kind  or  in  the  same  place  in  two  dif- 
ferent persons.  Esmarch2  gives  the  good  general  rule  that  the 
patient  should  lie  on  the  left  side,  as  the  chief  and  most  con- 
stant fold  of  membrane,  the  plica  transversalis  recti  of  Kohl- 
rausch,  projects  from  the  right  wall.  The  instrument  should 
be  passed  gently,  for  force  is  never  allowable  here  more  than  in 
the  similar  operation  on  the  urethra  ;  and  when  an  obstruction  is 
met  with  the  handle  should  be  gently  rotated,  withdrawn,  and 
again  passed  onward  till  by  frequent  repetitions  of  this  manoeu- 
vre it  is  made  to  pass.  If  this  does  not  suffice,  a  Davidson's 
syringe  may  be  attached  to  the  lower  end  of  the  bougie  and  a 
stream  of  warm  water  thrown  into  the  bowel  until  it  is  moder- 
ately distended,  when  the  bougie  will  generally  pass  with  ease. 
For  measuring  the  extent  of  a  stricture,  an  ingenious  instru- 
ment has  been  devised  by  Laugier,  which  consists  in  attaching 
a  thin  rubber  glove-finger  to  the  end  of  a  perforated  bougie. 
This  is  passed  up  the  bowel  empty,  and  then  inflated  and  with- 
drawn till  it  reaches  the  upper  limit  of  the  obstruction.  It  is 
safer  than  the  !><>ii(/ie  d  boule,  for  it  may  be  allowed  to  collapse 
before  being  withdrawn,  and  all  straining  of  the  diseased  tissues 
may  thus  be  avoided. 

Houston:  Dublin  Hospital  Reports,  vol.  v..  1830. 
5  Die  Krankheiten  des  Mastdarmes  und  des  Afters,  Pitha  und  Billroth's  Chirurgie. 


GENERAL    RULES    REGARDING    EXAMINATION,    ETC.  73 

In  case  disease  actually  exists  high  up  in  the  bowel,  the  at- 
tempt to  pass  an  instrument  is  full  of  danger.  A  patient  may 
easily  recover  from  a  false  passage  made  in  the  urethra,  but 
such  will  seldom  be  the  case  with  the  rectum,  for  here  when  the 
instrument  leaves  the  bowel  it  enters  the  peritoneum.  To  under- 
stand this  danger  it  is  only  necessary  to  remember  that  the 
bowel  is  generally  ulcerated  both  above  and  below  the  seat  of 
the  contraction,  and  is  sometimes  weakened  to  such  an  ex- 
tent that  it  will  allow  a  bougie  to  pass  through  it  without  the 
use  of  any  appreciable  force  on  the  part  of  the  surgeon.  The 
bowel  may  also  be  lacerated  without  being  directly  perforated 
by  the  bougie,  for  the  stricture  may  be  pushed  upward  or 
dragged  downward  on  the  point  of  the  instrument  till  the  bowel 
gives  way. 

Supposing,  now,  that  a  rectal  bougie  cannot  be  passed  eight 
or  ten  inches  up  the  bowel,  is  it  safe  on  this  account  alone  to 
make  a  diagnosis  of  stricture  high  up  \  I  should  hesitate  long 
before  doing  so,  and  should  make  many  careful  attempts  to  pass 
the  instrument  at  different  times,  resorting  to  injection  if  neces- 
sary, carefully  exploring  through  the  abdominal  wall  for  indu- 
ration, and  watching  for  the  usual  signs  of  obstruction.  There 
are  one  or  two  points  worthy  of  remembrance  in  this  connec- 
tion. The  first  is  that  the  obstruction  due  to  a  stricture  will 
always  be  at  the  same  point  in  the  canal  ;  and  another  is,  that 
when  a  bougie  has  once  become  engaged  in  a  stricture  it  is 
firmly  grasped,  and  the  resistance  to  its  withdrawal  is  equal  to 
that  encountered  in  introducing  it  farther.  The  feeling  con- 
veyed to  the  hand  under  these  circumstances  is  diagnostic,  and 
is  like  that  which  is  felt  when  the  effort  is  made  to  withdraw  a 
sound  from  the  grasp  of  a  stricture  in  the  urethra. 

Should  it  still  be  necessary  for  diagnosis,  the  speculum  may 
be  used  and  the  inside  of  the  rectum  illuminated.  I  have  post- 
poned any  reference  to  this  means  of  examination  till  the  present, 
because  it  will  generally  be  found  useful  only  after  the  others 
have  been  tried.  The  thorough  use  of  the  speculum  involves, 
almost  of  necessity,  the  administration  of  ether  and  the  stretch- 
ing of  the  sphincter  muscles  ;  to  try  to  use  it,  except  in  certain 
cases  for  obtaining  a  view  of  a  small  portion  of  the  rectum,  with- 
out these  adjuncts  is  almost  to  inflict  useless  pain  upon  the 
patient.  I  shall  not  attempt  any  description  of  the  infinite 
number  of  instruments  which  have  been  invented  for  this  pur- 


74 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


pose,  or  any  judgment  upon  their  relative  advantages,  but  will 
merely  say  that  the  best  vaginal  speculum  is  still  the  best  for 
the  rectum — that  of  Sims,  with  a  groove  where  the  blade  joins 
the  handle  for  the  sphincter  to  rest  in,  as  suggested  by  Van 


Fig.  29. — Helmuth's  Speculum. 

Buren,  and  a  slight  curving  over  of  the  end  to  keep  out  more  of 
the  mucous  membrane,  as  suggested  by  Helmuth.     (Fig.  29.) 

I  have  myself  added  one  more  to  the  number  of  these  instru- 
ments, made  after  a  pattern  suggested  to  me  by  Dr.  Sass,  and 
shown  in  Fig.  30.  It  is  one  which  I  use  especially  for  office 
work  without  an  assistant,  and  it  has  certain  advantages.  It 
avoids  the  especial  objection  to  all  the  two-  or  three-bladed  in- 
struments, which  is  that  the  blades  separate  at  almost  an  equal 


Fig.  30.— Author's  Speculum, 

distance  along  their  entire  length,  and  that  an  equal  amount  of 
dilatation  is  therefore  brought  to  bear  both  upon  the  anus  and 
rectum,  an  amount  which,  when  brought  to  a  degree  which  is 
unbearable  at  the  anus,  has  still  done  no  good  within  the  rectum. 


GENERAL  RULES  REGARDING  EXAMINATION,  ETC.     75 

With  this  instrument  the  hinge  is  at  the  anus  and  the  dilata- 
tion at  the  other  end  of  the  blades,  and  in  a  patient  with  a  lax 
sphincter  the  instrument  can  sometimes  be  opened  to  a  consider- 
able extent,  and  permit  of  an  inspection  of  a  considerable  part 
of  the  bowel  without  stretching  the  anus  enough  to  cause  much 
suffering.     The  fenestrated  blade  must  be  made  of  steel  to  give 


Fig.  31. — Fenestrated  Speculum. 


it  sufficient  strength.  It  is  an  instrument,  however,  much  more 
useful  for  treating  an  ulcer  within  the  rectum,  the  exact  seat 
of  which  is  already  known,  than  for  finding  the  ulcer  in  the  first 
place. 

The  fenestrated  instrument,  Fig.  31,  is  sometimes  useful  for 
inspecting  the  parts  just  within  the  anus  ;  and  a  long  vaginal 
cylindrical  speculum,  with  the  end  cut  at  such  an  angle  as  will 
best  expose  the  mucous  membrane,  may  sometimes  be  of  service 
in  bringing  into  view  a  small  portion  of  the  inner  surface  of  the 
bowel  high  up.    But,  after  all  have  been  tried,  none  will  be 


FlG.  32.— Bivalve  Speculum. 


found  better  for  any  purpose  than  a  small-bladed  Sims'1  s,  and 
without  ether  all  will  be  found  eminently  unsatisfactory. 

Almost  the  only  other  speculum  besides  these  which  I  have 
found  of  any  practical  value  is  the  bivalve  shown  in  Fig.  32, 
but  the  same  objection  applies  to  this  as  to  all  the  others,  that 
the  redundant  mucous  membrane  prolapses  between  the  blades 


76 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


to  such  an  extent  as  to  render  it  almost  useless,  and  that  when 
the  attempt  is  made  to  dilate  the  blades  sufficiently  to  over- 
come this,  the  sphincter  is  immediately  stretched  to  a  painful 
extent.  With  any  speculum  the  wooden  depressor,  shown  in 
Fig.  33,  may  be  found  a  useful  addition. 


Fig.  33. — Rectal  Depressor.  (Van  Buren.) 

The  idea  of  the  endoscope  has  been  applied  to  the  rectum  in 
the  use  of  the  instrument  shown  in  Fig.  34.  It  is  of  little,  if 
any,  practical  value,  however ;  its  introduction  beyond  the 
point  which  can  be  reached  by  a  long  vaginal  speculum  being 
exceedingly  difficult,  and,  in  case  of  the  diseases  which  it  is 
supposed  to  enable  the  surgeon  to  see,  not  devoid  of  danger ; 
and  the  mirror  quite  useless. 

It  is  almost  useless  to  attempt  to  see  within  the  rectum  with 
any  kind  of  a  speculum  without  first  overcoming  the  sphincter 
muscle,  and  the  only  effectual  way  of  doing  this  is  by  stretch- 
ing it.     It  is,  therefore,  my  own  practice  to  resort  to  this  pro- 


Fig.  34. — Colonoscope  of  Bodenhamer. 

cedure  in  every  case  of  doubtful  character,  nor  was  I  led  to  this 
practice  without  many  trials  of  the  various  specula?  in  the 
market,  all  ending  in  disappointment.  The  stretching  of  the 
sphincter  is  in  itself  an  entirely  harmless  proceeding,  but  one 
which  necessitates  the   previous  administration   of  ether.      It 


GENERAL    RULES    REGARDING    EXAMINATION,    ETC.  77 

should  not,  however,  be  done,  as  was  at  one  time  the  usual 
method,  and  as  it  is  often  done  at  present,  by  introducing  the 
thumbs  back  to  back,  and  forcibly  and  suddenly  separating 
them  till  they  touched  the  tuberosities  on  each  side.  In  this 
way  the  mucous  membrane  is  often  lacerated  at  one  or  more 
points,  and  the  paralysis  is  not  as  effectual  as  when  the  stretch- 
ing is  done  more  gradually.  A  better  way  is  to  introduce  first 
one  finger,  then  two,  and  finally  four,  in  the  form  of  a  funnel 
and  gradually  bore  into  the  anus  ;  or  to  introduce  two  fingers, 
and  make  pressure  on  all  sides  of  the  opening  till  it  becomes 
patulous.  Instead  of  one  or  two  seconds,  this  procedure  should 
occupy  five  minutes,  and  should  be  done  so  gently  as  not  to 
lacerate  the  mucous  membrane.  The  dilatation  should  also  be 
made  to  include  the  internal  as  well  as  the  external  muscle.  If 
this  dilatation  be  carried  to  a  sufficient  extent,  the  firm,  cord- 
like feel  of  the  external  sphincter  may  be  made  to  completely 
disappear.  The  paralysis  induced  in  this  way  is  always  tem- 
porary, and  I  have  never  known  it  to  be  followed  even  by  a 
temporary  incontinence  of  faeces.  After  coming  out  of  the 
ether,  the  patients  are  usually  conscious  of  only  a  sense  of  sore- 
ness in  the  part,  but  are  never  incapacitated  for  their  usual 
duties.  This  stretching  of  the  sphincters  is  a  necessary  prelim- 
inary in  almost  all  operations  within  the  rectum. 

With  the  patient  in  the  proper  position  on  the  side,  under 
the  influence  of  ether,  with  the  sphincter  thoroughly  dilated, 
and  with  a  good  reflected  light,  the  lower  four  or  five  inches  of 
the  rectum  may  be  thoroughly  illuminated  and  examined. 

As  a  rule,  however,  a  speculum  will  be  found  of  very  little 
use  in  the  examination  of  stricture,  but  is  chiefly  available 
for  obtaining  a  good  view  of  other  morbid  processes  affecting 
the  rectal  pouch  and  for  making  applications  to  them  or  per- 
forming operations  for  their  cure.  By  its  aid  the  different  va- 
rieties of  ulceration  may  be  inspected  and  thus  differentiated, 
the  internal  openings  of  fistulse  may  be  located,  and  the  whole 
rectal  pouch  may  be  brought  into  view. 

From  what  has  been  said  it  may  readily  be  seen  that  the 
diagnosis  of  stricture  above  the  reach  of  touch  or  vision  is  a  dif- 
ficult matter.  So  difficult  is  it  in  some  cases  that  no  less  an 
authority  than  Syme  has  written  that  there  is  good  reason  to 
suspect  the  honesty  of  a  man  who  pretends  to  detect  such  a 
condition.     Such  is,  indeed,  the  case,  for  "strictures  high  up" 


78  DISEASES    OF    THE    RECTUM    AND    ANUS. 

are  favorites  among  a  certain  class  of  quacks,  and  the  passage 
of  a  bougie  two  or  three  times  a  week  for  an  indefinite  period  is 
profitable  business.  In  reality  strictures  above  the  rectal  pouch 
are  rare  ;  when  they  exist  they  are  usually  malignant,  for  this 
part  of  the  bowel  is  not  subject  to  the  influences  which,  by  ex- 
citing ulcerative  action,  result  in  the  cicatricial  contractions 
which  so  often  affect  the  lower  three  inches  of  the  rectum  ;  and 
malignant  disease  of  the  sigmoid  flexure  or  descending  colon 
will  manifest  itself  by  a  well-marked  train  of  constitutional  and 
local  symptoms,  and  can  generally  be  felt  better  through  the 
abdominal  wall  than  per  rectum. 

After  the  use  of  the  bougie,  which  is  at  best  an  uncertain 
means  of  diagnosis  for  this  condition,  and  after  a  study  of  the 
symptomatology,  and  a  careful  examination  through  the  abdo- 
minal wall,  there  is  still  one  other  means  of  exploration  open  to 
the  surgeon  if  he  have  a  sufficiently  small  hand — the  passage  of 
the  whole  hand  into  the  rectum.  A  hand  which  measures  seven 
and  a  half  inches  in  circumference  can  generally  be  passed 
easily  ;  one  measuring  more  than  nine  is  unfit  for  the  purpose. 
With  a  small  hand  there  is  no  danger  of  permanent  incontinence 
of  faeces,  but  the  sphincter  should  be  dilated  gently  and  grad- 
ually, rather  than  forcibly  torn  open.1 

When  the  anus  has  been  sufficiently  dilated  to  allow  the 
hand  to  enter  the  rectum,  if  the  bladder  is  empty,  the  arch  of 
the  pubes  may  be  felt  above  the  prostate ;  if  full  it  will  be 
easily  distinguished  at  the  same  point.  The  uterus  and  ovaries 
are  easily  made  out  anteriorly,  and  the  whole  curve  of  the  sac- 
rum may  be  followed  posteriorly.  The  next  point  to  feel  for  is 
the  spine  of  the  ischium  on  either  side,  and  with  this  as  a  guide, 

1  Dr.  R.  F.  Weir  (New  York  Medical  Record,  March  20,  1875)  was  led  to  the  fol- 
lowing conclusion  from  his  investigations  of  this  subject.  "  A  hand  of  less  than  26 
ctm.  may  be  introduced  17-19  ctm.  without  inconvenience,  but  not  more."  His 
measurements  showed  the  greatest  circumference  of  the  rectum  to  be  at  0  or  7  ctm. 
from  the  anus,  where  it  may  reach  to  25-30  ctm.  At  the  upper  part  of  the  middle 
third  it  is  not  more  than  20-25  ctm.,  and  thence  it  rapidly  diminishes,  being  not  more 
than  10-18  ctm.  at  the  middle  part  of  the  superior  third,  while  the  narrowest  part  is 
at  the  commencement  of  the  sigmoid  flexure. 

For  an  early  case  of  manual  exploration  see  Medico-Chirurgical  Transactions,  vol. 
i. ,  p.  1 2!).  Referred  to  by  Copeland,  Observations  on  the  Principal  Diseases  of  the  Rec- 
tum and  Anus.  London,  1814.  See  also  G.  Simon,  Ueber  die  kunstliohe  Erweiterung 
des  Anus  und  Rectum,  Arch.  f.  klin.  Chir.,  xv.,  1,  1872  ;  Dtsch.  Klin.  f.  Chir.,  Novem- 
ber, 1882  ;  W.  J.  Walsham  :  Some  Remarks  on  the  Introduction  of  the  Whole  Hand 
into  the  Rectum,  St.  Bartholomew's  Hospital  Reports,  vol.  xii. ,  187G,  p.  223. 


GENERAL    RULES    REGARDING    EXAMINATION,    ETC.  79 

the  greater  and  lesser  sciatic  notches  may  be  outlined.  The 
whole  brim  of  the  pelvis  may  be  traced,  and  the  external  and 
internal  iliac  arteries  followed  with  the  lingers.  All  this  may 
be  done  while  the  hand  is  in  the  rectal  pouch,  and  it  may  be 
done  upon  almost  any  patient,  male  or  female,  though  more 
easily  upon  the  female,  and  with  a  small  hand,  without  causing 
any  unpleasant  after-results.  But  in  many  persons  this  is  all 
that  can  be  gained  by  this  method,  for  the  anatomical  reason 
that  to  pass  the  hand  above  into  the  sigmoid  flexure  is  often  at- 
tended with  great  danger  from  the  narrowing  of  the  bowel  at 
this  point.  When  the  hand  is  met  by  a  sense  of  constriction 
at  about  the  level  of  the  third  sacral  vertebra,  where  the  lateral 
fold  of  Douglas  is  reflected  from  the  bowel,  the  limit  of  examin- 
ation has  been  reached,  and  no  force  should  be  used  to  over- 
come the  constriction,  which  can  only  be  accomplished  by  a 
rupture  of  the  peritoneal  coat.  In  many  cases,  however,  by 
carefully  following  the  natural  windings  of  the  canal,  and  by  a 
semi-rotatory  movement  of  the  hand,  combined  with  alternate 
flexing  and  extending  of  the  fingers,  this  point  of  danger  may 
be  surmounted,  and  the  hand  be  passed  fairly  into  the  sigmoid 
flexure,  and  sometimes  into  the  descending  colon.  Here  the 
common  iliacs,  the  bifurcation  of  the  aorta,  the  left  kidney,  and, 
in  fact,  nearly  all  of  the  abdominal  contents  may  be  touched. 

By  this  method  of  examination,  a  stricture  situated  in  the 
sigmoid  flexure,  or  even  in  the  descending  colon,  may  some- 
times be  discovered  after  all  other  methods  of  examination  have 
failed  ;  but,  as  we  have  shown,  the  method  is  not  always  ap- 
plicable, and  the  diagnosis  of  stricture  high  up  still  remains  one 
of  the  most  difficult  things  in  surgery.  In  the  great  majority 
of  cases  in  general  practice,  in  which  such  a  diagnosis  has  been 
made,  it  may  be  proved  false  by  the  introduction  of  a  full-sized 
bougie  after  a  few  trials,  and  in  the  remainder  the  diagnosis 
will  be  confirmed  sooner  or  later  by  the  well-marked  symptoms 
of  intestinal  obstruction. 

Before  attempting  any  surgical  operation  upon  the  rectum, 
the  bowels  should  be  thoroughly  emptied  by  a  cathartic.  It  is 
well  to  begin  with  three  compound  cathartic  pills,  or  with  five 
grains  of  mass,  hydrarg.  on  the  second  evening  before  the  oper- 
ation where  the  patient's  general  condition  admits  of  these 
remedies  ;  to  follow  them  with  a  slight  saline  or  a  dose  of  castor- 
oil  on  the  night  immediately  preceding  ;  and  finally  to  clear 


80 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


out  the  rectum  with  a  simple  enema  on  the  morning  of  the  day 
of  the  operation.  After  this  the  bowels  may  easily  be  confined 
for  a  week  if  desirable  without  inconvenience  to  the  patient, 
and  the  passage  ol*  hard  masses  of  faeces  over  a  wounded  surface 
is  avoided. 

In  all  operations  in  which  ether  is  used,  three  assistants  will 
be  necessary  and  four  are  preferable.  Each  assistant  should 
have  his  place  assigned  to  him — one  for  the  anaesthetic,  one  to 
keep  each  leg  of  the  patient  in  position  and  to  hold  the 
speculum,  and  one  to  assist  the  operator  in  whatever  way  may 
be  necessary.     A  state  of  profound  anaesthesia  will  generally  be 


Fig.  35. — Paqnelin's  Thermo-cautery. 


necessary,  thongh  with  intelligent  patients  I  have  often  taken 
advantage  of  the  primary  anaesthetic  state  which  ether  produces 
for  opening  abscesses,  dividing  fistulae,  and  cutting  off  external 
haemorrhoids. 

Accidents  are  not  common  in  operations  about  the  rectum, 
but  there  is  one  for  which  the  surgeon  should  always  be  pre- 
pared—haemorrhage. For  tliis  reason  a  bottle  of  dry  per- 
sulphate of  iron,  and  a  Paquelin's  thermo-cautery  should 
always  be  at  hand.  The  thermo-cautery  as  now  made,  Fig.  35, 
is  not  at  all  cumbersome,  and  is  exceedingly  useful  in  many 
operations  about  the  rectum.  The  bulb  containing  the  sponge 
for  the  benzine  should  never  be  filled  with  an  excess  of  fluid 


GENERAL    RULES    REGARDING    EXAMINATION,    ETC.  81 

which  may  run  down  into  the  point  and  interfere  with  the 
working  of  the  instrument ;  and  the  platinum  point  should  be 
thoroughly  heated  before  the  assistant  begins  to  use  the  bulb  to 
drive  the  air  over  the  sponge.  If  proper  regard  be  paid  to  these 
points  the  instrument  is  a  most  reliable  one,  and  in  every  case 
where  hemorrhage  is  to  be  apprehended  it  should  be  ready  for 
use,  and  an  alcohol  lamp  or  gas  jet  should  be  ready  to  heat  the 
point — which  is  sometimes  forgotten. 

A  haemorrhage  seldom  occurs  from  the  rectum  after  a  sur- 
gical operation — so  seldom  as  to  be  almost  unknown — which 
cannot  be  controlled  either  by  the  ordinary  methods  or  by  the 
cautery  and  by  packing  the  rectum.  The  rectum  may  be 
packed  with  either  sponges  or  lint,  and  these  may  be  used 
either  with  or  without  the  persulphate  of  iron.  Most  cases  of 
bleeding  may,  however,  be  controlled  by  the  use  of  simple  ice- 
water  and  a  moderate  amount  of  pressure  properly  applied  to 
the  bleeding  surface  without  the  necessity  for  a  systematic 
packing  of  the  whole  rectal  cavity.  It  is  not  long  since  I  was 
called  in  the  middle  of  the  night  to  stop  the  bleeding  from  an 
incision  which  I  had  made  into  an  abscess  of  the  ischio-rectal 
fossa  about  eight  hours  before.  I  found,  as  is  too  often  the 
case,  that  the  patient  was  thoroughly  immersed  in  a  mixture  of 
blood  and  persulphate  of  iron,  which  covered  him  from  the 
pubes  to  the  middle  of  the  back  and  had  thoroughly  permeated 
the  bed.  On  entering  the  room  I  was  informed  that  the  wound 
had  been  carefully  stuffed  with  lint  and  persulphate  of  iron 
"several  times,"  and  that  the  case  was  undoubtedly  one  of 
hemorrhagic  diathesis.  A  case  like  this  is  easily  managed. 
The  treatment  consists  first  of  all  in  providing  a  good  light, 
next  in  cleaning  up  the  general  nastiness,  then  in  finding  the 
bleeding  point  and  making  pressure  upon  it.  In  this  case  the 
bleeding  came  from  a  small,  spouting,  cutaneous  vessel  and  was 
at  once  controlled  by  filling  the  incision  I  had  made  with  picked 
lint  thoroughly  pressed  home  into  the  wound.  Most  cases  of 
bleeding  m&y  be  controlled  in  the  same  way,  but  where  the 
haemorrhage  is  within  the  bowel  it  is  not  always  easy  to  make 
pressure  upon  the  right  point  without  packing  the  entire  rectal 
cavity.  For  this  purpose  Allingham1  recommends  the  follow- 
ing procedure  which  is  equally  simple  and  effectual. 

1  Op.  cit.,  p.  154. 


82  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Take  a  medium-sized  bell-shaped  sponge  and  pass  a  strong 
double  ligature  through  the  apex  from  within  outwards  and 
back  again,  so  as  to  include  a  considerable  part  of  the  sponge 
in  the  bite  of  the  ligature — enough  so  that  when  the  cord  is 
pulled  upon  strongly  from  below  it  will  not  tear  out.  After 
wetting  the  sponge  and  squeezing  it  out,  it  should  be  powdered 
with  the  persulphate  of  iron  and  passed  as  far  up  the  rectum  as 
possible  with  the  aid  of  a  rectal  bougie,  the  apex  being  up- 
ward. The  whole  of  the  rectum  below  the  sponge  should  then 
be  carefully  filled  with  pledgets  of  cotton-wool  powdered  over 
with  the  iron,  each  roll  being  carefully  and  firmly  packed  away. 
An  exceedingly  large  quantity  of  cotton  may  be  crowded  into 
the  rectum  in  this  way,  and  when  the  cavity  is  filled  the  sponge 
should  be  drawn  down  by  means  of  the  string  hanging  out  of 
the  anus,  so  that  the  whole  mass  may  be  tightly  compressed. 
If  the  bowel  has  been  thoroughly  emptied  as  recommended, 
such  a  plug  may  be  left  in  for  a  week  or  more  without  causing 
any  discomfort,  and  no  bleeding  can  occur  while  it  is  in  place. 
If,  however,  it  is  intended  to  leave  the  packing  in  for  such  a 
length  of  time,  it  is  better  to  pass  a  large-sized,  stiff  rubber  male 
catheter  through  the  apex  of  the  sponge  and  pack  the  cotton 
around  it.  In  this  way  a  chance  is  given  for  wind  and  fluid 
faeces  to  escape.  By  this  simple  means,  when  properly  used, 
any  hemorrhage  after  an  operation  upon  the  rectum  may  be 
controlled. 

After  operations  upon  the  rectum  or  anus,  a  suppository  of 
one  grain  of  opium  may  generally  be  placed  in  the  rectum  with 
advantage,  and  the  surgeon  should  always  be  provided  with 
them.  Those  made  of  gelatine  by  Mitchell,  of  Philadelphia, 
have  given  me  great  satisfaction.  They  are  smaller,  softer,  and 
less  irritating  than  those  usually  made  of  cacao  butter,  and  they 
withstand  the  changes  of  temperature  better.  The  usual  dress- 
ing consists  in  placing  a  pad  of  lint  and  a  soft  towel  over  the 
anus,  and  fastening  them  in  place  with  a  T  bandage.  This  form 
of  bandage  will  generally  be  found  the  best  in  any  case  where  a 
continuous  dressing  is  needed. 

Lister's  impervious  dressing  has  been  applied  to  wounds  of 
the  rectum  in  some  of  the  more  extensive  operations,  such  as 
excision  of  cancer,  by  the  German  surgeons  ;  but  it  has  not  be- 
come popular,  and  the  use  of  free  drainage  and  plenty  of  car- 
bolic acid  or  some  other  disinfectant  is  generally  considered  all 


GENERAL    RULES    REGARDING    EXAMINATION,    ETC.  83 

that  is  necessary  or  desirable  in  this  line.  Verneuil  recommends 
the  free  nse  of  a  solution  of  chloral  as  an  antiseptic  for  this 
part. 

Wounds  of  the  rectum  will  always  heal  more  kindly  when 
the  patient  is  in  the  horizontal  position  than  when  standing  or 
walking,  there  being  less  tendency  to  venous  congestion  in  the 
former  case.  Almost  any  operation  may  result  in  a  sluggish 
open  sore  if  the  patient  be  allowed'  to  disregard  this  rule. 

Retention  of  urine  is  of  frequent  occurrence  after  operations 
upon  these  parts,  both  in  men  and  women,  and  it  should  always 
be  in  the  mind  of  the  surgeon.  It  is  not  generally  of  long  dura- 
tion, and  it  may  often  be  overcome  by  a  bath  and  hot  applica- 
tions, without  having  recourse  to  the  catheter.  The  following 
case  conveys  a  lesson  in  this  matter  which  should  never  be  for- 
gotten. 

Case.  Death  from  Retention  of  Urine. — I  was  requested 
several  years  ago  by  a  gentleman  to  make  an  autopsy  on  his 
brother,  who  had  died  very  suddenly  and  unexpectedly  after 
being  confined  to  his  bed  about  a  week  with  an  abscess  near  the 
anus.  Before  the  abscess  appeared  the  man  had  been  in  perfect 
health,  and  was  apparently  doing  well  up  to  the  moment  of  his 
death,  as  the  abscess  had  been  opened  on  the  day  before,  with 
great  relief  to  pain,  and  was  discharging  freely.  I  made  the 
autopsy,  as  requested,  and  found  a  bladder  distended  to  the 
point  of  rupture,  the  urine  dammed  back  upon  the  kidneys, 
which  were  gorged  with  blood,  and  the  cerebral  vessels  greatly 
congested.  The  man  had  died  very  suddenly  in  a  convulsion. 
A  little  questioning  revealed  the  fact  that  from  the  first  day  of 
the  disease  there  had  been  retention  of  urine  with  dribbling 
from  the  overflow  ;  and  that  for  the  pain  arising  from  this  con- 
dition opium  had  been  freely  given  up  to  the  day  of  death. 

Once  during  his  sickness  an  old  woman  in  the  house  had  ap- 
plied a  hot  flannel  cloth  over  the  bowels,  and  the  patient  had 
passed  an  immense  amount  of  urine.  The  condition  of  the 
bladder  seemed  to  have  entirely  escaped  the  notice  of  his  med- 
ical attendant,  as  it  probably  has  escaped  the  attention  of  most 
surgeons  at  some  time,  though,  fortunately,  without,  as  in  this 
case,  a  fatal  result. 


CHAPTER  IV. 

INFLAMMATION  OF   THE  RECTUM. 

Cases  of  Proctitis. — Varieties  :  Acute,  Chronic,  Primary,  Secondary,  Localized,  Gen- 
eral.— Symptoms  and  Course  of  each  Variety. — Causes  of  Proctitis  :  Direct  Prop- 
agation, Foreign  Bodies,  Drastic  Cathartics,  Gout,  Pederasty,  Gonorrhoea. — 
Treatment. 

The  case  which  follows  is  not  only  interesting  from  its  rarity, 
but  as  being  a  good  example  of  the  affection  under  consideration. 

Case.  Inflammation  of  the  Rectum. — Woman,  married, 
aged  twenty-three,  mother  of  two  children  :  youngest  six  months 
old.  Patient  has  always  been  constipated,  and  for  years  has 
been  in  the  habit  of  using  purgatives  whenever  she  desired  an 
evacuation.  For  the  past  six  months  has  noticed  occasional 
discharge  of  blood  and  slime  from  the  rectum.  Now  suffers 
great  pain  on  defecation,  and  the  amount  of  blood  and  muco- 
purulent matter  is  increasing  so  that  while  at  first  it  only  came 
away  when  at  stool,  it  now  comes  several  times  a  day.  With 
this  she  has  much  pain  in  the  rectum  at  all  times,  and  is  in  poor 
general  condition,  having  lost  her  ap]3etite,  and  being  unable  to 
sleep. 

A  careful  examination  of  the  rectum  showed  it  to  be  con- 
gested, hot,  and  painful,  as  far  as  the  eye  could  see  ;  but  nothing 
else  was  apparent.  The  amount  of  discharge  suggested  the  idea 
of  a  gonorrhoea  of  the  rectum,  but  there  was  no  inflammation  of 
the  vagina,  and  careful  questioning  of  the  patient  left  no  room 
for  such  a  suspicion.  The  cause  of  the  trouble  in  this  case  was 
not  difficult  to  find,  the  patient  having  been  in  the  habit  of  tak- 
ing large  doses  of  patent  cathartic  remedies  two  or  three  times 
a  week  for  a  long  time  ;  and  as  the  trouble  developed  imme- 
diately after  her  last  confinement,  this  may  not  have  been  with- 
out its  influence  as  an  exciting  cause. 

The  next  case  is  one  of  simple  congestion  of  the  rectal  mu- 
coua  membrane,  brought  about  by  retained  faeces  and  uterine 
disorder. 


INFLAMMATION    OF    THE    KECTUM.  85 

Case.  Congestion  of  the  Rectum. — Mrs.  Gf ,  aged  thirty- 
seven,  mother  of  three  children.  The  patient,  a  delicate  and 
rather  anaemic  lady,  had  not  been  in  good  health  for  some  time 
past,  but  had  never  had  any  trouble  with  the  rectum  until  one 
month  before  consulting  me.  At  that  time  she  was  surprised  to 
find  that  she  had  passed  a  considerable  quantity  of  blood  while 
at  stool,  and  this  haemorrhage  had  been  repeated  at  intervals  of 
about  a  week  up  to  the  day  before  my  visit.  There  had  never 
been  any  pain  in  the  rectum  or  anus,  or  any  signs  of  haemor- 
rhoids, and  a  careful  examination  failed  to  reveal  any  source  of 
the  haemorrhage.  The  lady  complained,  however,  of  a  good  deal 
of  discomfort  in  the  back  and  pelvis  ;  had  missed  her  last  men- 
strual period,  and  was  decidedly  constipated.  An  examination 
showed  a  uterus  enlarged  and  retroverted,  and  a  considerable 
mass  of  faeces  in  the  sigmoid  flexure  and  descending  colon,  and 
treatment  was  begun  for  these  conditions.  The  bowels  were 
unloaded  of  many  scybalous  masses  by  means  of  frequent  ene- 
mata,  and  the  uterine  condition  was  so  far  improved  by  treat- 
ment that  the  menses  soon  reappeared,  and  the  pain  and  dis- 
comfort passed  away.  The  bleeding  from  the  rectum  never 
recurred,  nor  has  the  patient  ever  again  had  her  attention  called 
to  that  part  up  to  the  present  time — four  years  later. 

Here  the  congestion  of  the  mucous  membrane  relieved  itself 
by  a  discharge  of  blood  from  the  over-distended  veins.  Had 
the  conditions  remained,  other  symptoms  would  in  all  proba- 
bility have  soon  developed,  such  as  heat  and  tension  at  the 
anus,  possibly  a  slight  mucous  discharge,  pruritus  ani,  and, 
finally,  haemorrhoids.  There  are  various  other  causes  of  such 
a  condition,  besides  impacted  faeces  or  menstrual  disorders, 
such,  for  example,  as  excess  at  table,  prolonged  horseback 
exercise  or  carriage  riding,  pregnancy,  drastic  purgatives,  and, 
in  short,  anything  which  tends  to  produce  hyperaemia  of  the 
pelvic  viscera. 

In  most  cases  of  bleeding  from  the  rectum  a  diagnosis  of 
congestion  alone  would  be  an  error,  for  a  congestion  sufficiently 
marked  to  cause  haemorrhage  is  rare,  and  bleeding  is  in  most 
cases  a  symptom  either  of  haemorrhoids,  polypus,  or  some  more 
serious  affection.  But  in  this  case  there  was  no  such  cause, 
and  the  subsequent  history  of  four  years  with  no  other  rectal 
symptoms  tends  to  strongly  confirm  the  diagnosis. 

A  proctitis  may  be  either  acute  or  chronic,   primary   or 


86  DISEASES    OF    THE    RECTUM    AND    ANUS. 

secondary,  localized  or  general.  The  localized  variety  is  gener- 
ally due  to  the  injury  inflicted  by  a  foreign  body,  or  to  some 
irritation  acting  upon  a  small  part  of  the  rectal  surface.  In  the 
acute  form  the  inflammation  does  not  extend  deeper  than  the 
mucous  membrane,  which  is  congested  and  hyperaemic.  In  the 
chronic,  the  inflammation  involves  the  submucous  and  muscular 
layers.  The  acute  generally  ends  in  resolution  in  from  eight  to 
fourteen  days  where  the  cause  can  be  found  and  removed.  It 
may,  however,  in  severe  cases  go  on  to  actual  gangrene  and  ter- 
minate fatally.  The  chronic  results  in  infiltration  and  consequent 
thickening  of  the  rectal  wall,  and  may  end  in  ulceration,  either 
superficial  and  confined  to  the  epithelial  layer  of  the  mucous 
membrane,  or  deep  and  involving  the  whole  thickness  of  the 
mucous  layer.  What  is  described  a  follicular  ulceration  (ulcer- 
ation affecting  the  mouths  of  the  tubular  follicles)  may  result 
from  chronic  inflammation,  and  these  ulcers,  which  are  very 
minute  at  first,  may  coalesce  and  gain  in  depth  till  they  cause 
perforation  of  the  bowel.  When  the  perforation  is  above  the 
peritoneal  reflection  a  fatal  peritonitis  may  result ;  when  lower 
down,  an  abscess  or  fistula  (see  Fistula).  A  chronic  proctitis 
may  in  this  way  be  a  cause  of  stricture,  and  may  result  in  the 
hypertrophy  known  as  chronic  parenchymatous  proctitis. 

The  symptoms  of  this  affection  have  been  partially  detailed 
in  the  two  cases  which  have  been  related.  They  are,  in  the 
acute  form,  a  sensation  of  heat  and  weight  in  the  part  which 
may  amount  to  actual  pain,  and  may  involve  the  bladder, 
uterus,  and  sacral  region,  and  radiate  into  the  loins  and  down 
the  thighs.  The  anus  also  becomes  painful,  red  and  contracted, 
and  in  children  the  mucous  membrane  may  become  slightly 
everted  from  the  swelling  and  tenesmus.  The  evacuations  soon 
become  painful  and  increased  in  number,  and  the  fa3ces  are 
streaked  with  mucus,  blood,  and  pus.  There  is  apt  to  be  also 
a  train  of  symptoms  referable  to  the  bladder  and  to  the  gener- 
ative organs,  such  as  painful  micturition,  cystitis,  and  leucor- 
rhcea. 

With  these  local  symptoms  there  may  be,  as  in  the  case 
reported,  more  or  less  constitutional  disturbance,  fever,  and  loss 
of  appetite.  As  the  discharge  from  the  inflamed  surface  in- 
creases in  amount,  the  desire  to  empty  the  rectum  produces 
more  frequent  evacuations,  so  that  while  at  first  the  faeces  only 
are  stained  with  pus  and  blood,  later  the  evacuations  consist 


INFLAMMATION  OF  THE  RECTUM.  87 

entirely  of  the  muco-purulent  matter,  and  the  anus  may  become 
excoriated  by  the  discharge. 

In  the  chronic  form  the  symptoms  are  all  less  marked.  The 
diarrhoea  may  alternate  with  constipation,  and  the  discharge 
will  occur  only  at  the  time  of  defecation.  This  condition  may 
last  for  years.  An  examination  of  the  rectum  during  the  acute 
stage  of  proctitis  will  generally  cause  considerable  pain.  The 
rectal  mucous  membrane  will  be  found  intensely  congested,  and 
the  temperature,  as  shown  by  the  thermometer  or  even  by  the 
finger,  will  be  increased.  In  the  chronic  stage,  the  solitary 
glands  may  occasionally  be  recognized  as  small  round  promi- 
nences in  the  substance  of  the  mucous  membrane. 

Proctitis  is  generally  found  associated  with  stricture  of  the 
rectum  and  is  secondary  to  it.  In  these  cases  the  mucous  mem- 
brane below  the  stricture  will  be  found  congested  and  covered 
with  pus  or  bloody  mucus,  while  above  it  is  eroded  and  de- 
stroyed, sometimes  only  superficially,  at  others  for  its  entire 
depth.  In  such  cases  the  other  layers  will  be  found  hypertro- 
phied,  especially  the  circular  muscular  layer. 

The  causes  which  may  produce  proctitis  are  numerous.  It 
may  result  by  direct  propagation  and  continuity  of  surface  from 
inflamed  haemorrhoids  or  prolapsus,  or  from  any  erosion  about 
the  anus,  such  as  a  mucous  patch  or  eczema.  It  may  be,  and 
often  is,  caused  by  the  presence  of  foreign  bodies,  or  of  hardened 
faeces  and  indigestible  remains  of  food  which  act  as  foreign 
bodies,  and  by  irritating  suppositories,  injections,  or  medicinal 
applications.  As  in  the  case  given  above,  it  may  be  caused  by 
the  abuse  of  drastic  purgatives  such  as  aloes,  gamboge,  or  even 
rhubarb  in  excess.  It  has  been  seen  to  result  fro(im  prolonged 
sitting  upon  a  cold  or  wet  seat,  and  when  founo^  An  children  it 
will  generally  be  due  to  the  presence  of  worms.  V  It  may  be  a 
symptom  of  gout  (Esmarch,  Bushe)  alternating  with  the  mani- 
festation of  the  disease  in  its  usual  seat,  and  there  may  be  a 
true  diphtheria  of  the  rectum,  as  there  may  be  of  the  vagina, 
and  the  formation  of  a  membrane  similar  to  that  seen  in  the 
throat.  Again,  the  disease  may  result  both  in  men  and  women 
from  the  habit  of  passive  pederasty,  and  in  such  cases  may  be 
due  either  to  mechanical  violence  or  to  the  inoculation  with 
gonorrhceal  pus.  A  true  gonorrhoea  of  the  rectum,  whether 
caused  in  this  way  or  by  direct  inoculation  in  women  by  pus 
which  is  passing  over  the  anus  from  the  vagina,  is  very  rare. 


88  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Tardieu  '  lias  never  observed  a  single  case.  Gosselin a  saw  only 
one  case  at  Lourcine  in  three  years.  Rollet 3  reports  a  case 
caused  by  direct  inoculation  from  the  penis  to  the  rectum  in  a 
patient  who  was  in  the  habit  of  using  a  finger  in  the  anus  to 
provoke  a  passage.  A.  Boniere4  found  it  very  difficult  to  inoc- 
ulate the  rectal  mucous  membrane  with  gonorrhceal  pus  placed 
upon  it  through  a  tube,  though  the  anus  was  easily  affected. 
On  the  other  hand,  Requin 5  believes  it  almost  sure  to  follow 
passive  pederasty  with  a  person  suffering  from  gonorrhoea. 
Thiery  also  believes  in  true  gonorrhoea  of  the  rectum  and  re- 
ports the  following  case  : 6 

Case.  Gonorrlicea  of  the  Rectum. — The  patient,  a  clandes- 
tine prostitute,  aged  twenty-four,  complained  of  weight  and 
shooting  pain  in  the  pelvis,  of  pain  in  defecation,  and  of  a  con- 
stant thick  discharge  from  the  bowel ;  also  that  walking  was 
difficult.  There  was  a  well-marked  funnel-shaped  depression 
of  the  anus ;  the  anal  folds  were  obliterated  ;  the  sphincter 
weak  and  dilated.  A  vaginal  speculum  of  ordinary  size  passed 
easily.  The  lower  rectum  was  acutely  inflamed,  covered  with 
thick  discharge,  studded  with  bright  red  points,  and  bled  when 
wiped  with  wool.  The  rectal  follicles  were  enlarged  and  dis- 
charging pus.  The  patient  confessed  to  intercourse  with  dis- 
eased men.  The  treatment  consisted  of  lotions  of  borax  and 
red  cinchona  bark,  and  finally  of  injections  of  oak  bark  with 
sitz-baths  and  iron  internally.  A  cure  was  effected  in  three 
weeks. 

The  diagnosis  of  gonorrhceal  proctitis  will  rest  upon  the 
amount  and  purulent  character  of  the  discharge,  and  upon  the 
existence  of  gonorrhoea  of  the  vagina  in  women  ;  or  the  confes- 
sion of  unnatural  intercourse  with  a  diseased  person,  in  men. 

The  treatment  of  proctitis  consists  first  of  all  in  an  endeavor 
to  discover  and  remove  the  cause  of  the  congestion,  be  it  what 
it  may.  In  the  acute  stage,  the  pain  and  tenesmus  may  be  over- 
come by  warm  baths,  and  anodyne  injections  of  starch-water 
with  a  few  drops  of  laudanum.    The  bowels  should  be  kept 

1  Etudes  Medico-k:gales  sur  les  Attentats  aux  Moeurs,  4th  ed.,  1862,  p.  179. 

sArch.  Gtn'l.  de  Med.,  1854. 

3 Diet.  Enc.  des  Sci.  Med.,  Art.  Rectum. 

4  R'Jcherches  Nouvelles  sur  la  Blennorrhagie.  Arch.  Gen'L  de  Med.,  April,  1874. 

6  Elements  de  Path.  Med.  Rectite,  t.  i,  p.  729. 

"Presae  Med.  Beige,  No.  26,  1882. 


INFLAMMATION    OF   THE    KECTUM.  89 

open  by  laxatives,  such  as  castor-oil,  or  preferably  the  saline 
cathartics  in  small  doses.  The  patient  should  also  be  confined 
to  the  bed,  and  placed  upon  a  diet  chiefly  of  milk.  In  the 
chronic  stage  astringents  are  indicated,  such  as  alum  and  tan- 
nin, and  to  these  may  be  added  suppositories  of  iodoform  (gr. 
v.),  and  the  same  rules  with  regard  to  rest  and  diet  should  be 
observed. 


CHAPTER  V. 

ABSCESS  AND   FISTULA. 

Abscess,  divided  into  Superficial  and  Deep. — Superficial  Abscesses. — Simple  Furun- 
cles :  Causes  ;  Characters  ;  Results  ;  Treatment.  —  Suppuration  of  External 
Hasmorrhoid. — Suppuration  of  Internal  Hemorrhoid. — Diffuse  Inflammation  of 
Subcutaneous  Tissue  :  Causes  ;  Symptoms  ;  Treatment. — Form  of  Incision. — Deep 
Abscesses. — Divided  into  Abscess  of  the  Ischio-Rectal  Fossa  and  of  the  Superior 
Pelvi-Rectal  Space. — Description  of  Superior  Pelvi-Rectal  Space. — Causes  of  Deep 
Abscess. — Residual  Abscess. — Symptoms  and  Cases  of  Deep  Abscess. — Dangers  of 
Deep  Abscess. — Formation  of  Deep  and  Extensive  Fistulas. — Horse-shoe  Abscess. 
— Idiopathic  Gangrenous  Cellulitis. — Reasons  why  Abscesses  do  not  Heal  Spon- 
taneously. —  Diagnosis.  — Prognosis.  — Treatment. —  Incisions  and  Subsequent 
Treatment  of  Deep  Abscess. — Danger  of  Incontinence. — Relief  of  Incontinence 
by  Operation. — Fistula. — Generally  due  to  Abscess. — Divided  into  Superficial  and 
Deep. — Complete  Fistula. — External  Fistula. — Internal  Fistula. — Description  of 
Superficial  Fistulas. — How  to  Detect  an  Internal  Opening. — Location  of  Internal 
Opening. — Description  of  Track  of  Fistula. — Symptoms  of  Superficial  Fistula. — 
Deep  Fistula.— Fistula  with  Numerous  External  Openings. — Pelvic  Fistulas. — 
Blind  Internal  Fistula. — Ulceration  of  Rectum  Causing  Internal  Fistula. — Treat- 
ment.— Spontaneous  Cure. — Advisability  of  Operation. — Fistula  in  Relation  to 
Phthisis. — Contra-indicatioDS  to  Operation.— Treatment  by  Cauterization. — The 
Ligature. — The  Elastic  Ligature. — Galvano-Cautery. — How  to  Pass  Ligature. — 
Incision. — Description  of  Operation. — Author's  Knife  for  Fistula. — Division  of 
Deep  Tracks. — Treatment  of  Track  running  up  the  Bowel. — Treatment  of  Blind 
External  Variety  ;  of  Horse-shoe  Variety  ;  of  Fistula  with  Numerous  External 
Openings.— Dressing  after  Incision. — Packing  the  Incision. —  Hasmorrhage  in 
Operation. — Treatment  of  Blind  Internal  Variety. — Incurable  Fistulas. — Treat- 
ment of  Deep  and  Extensive  Tracks. — Fistula  with  Stricture. 

Abscesses  in  the  region  of  the  anus  and  rectum  are  best  class- 
ified according  to  their  anatomical  location  into  superficial  and 
deep.     Of  each  of  these  there  are  several  different  varieties. 

Considering  first  the  superficial  variety,  the  simplest  form 
will  be  found  to  be  that  which  involves  the  skin  of  the  margin 
of  the  anus  alone,  and  which  generally  originates  in  one  of  thu 
minute  glands  of  the  part.  Such  an  abscess  or  furuncle,  for  it 
is  really  only  a  furuncle,  may  be  due  to  traumatism,  or  to  any 
irritation,  such  as  the  use  of  improper  paper  after  defecation, 
prolonged  walking  or  horse-back  riding,  a  menstrual  discharge, 
or  a  discharge  due  to  diarrhoea  or  dysentery. 


ABSCESS    AND    FISTULA.  91 

This  form  of  disease  is  always  distinctly  circumscribed,  is 
generally  about  the  size  of  an  almond,  is  found  by  preference  in 
robust  persons,  more  often  in  men  than  women,  seldom  in  old 
people,  and  almost  never  in  children.  It  generally  goes  on  rap- 
idly to  suppuration,  breaks  spontaneously  on  the  cutaneous 
surface,  and  heals  without  the  formation  of  fistula,  though  in 
cachectic  or  phthisical  patients  it  may  pursue  a  contrary  course, 
the  skin  over  it  becoming  thin  and  violet  colored,  and  finally 
rupturing,  leaving  a  permanent  subcutaneous  fistula. 

The  treatment  of  such  an  abscess  consists  chiefly  in  the  at- 
tempt to  avoid  the  formation  of  a  fistula,  and  the  best  means 
for  accomplishing  this  end  is  an  early  incision  as  soon  as  sup- 
puration appears  inevitable.  Resolution  is  hardly  to  be  ex- 
pected, but  it  may  be  sought  for  by  the  use  of  laxatives,  rest  in 
the  horizontal  posture,  and  the  application  of  a  bladder  of  ice. 
The  incision  should  be  large  enough  to  allow  of  the  free  exit  of 
pus,  and  after  it  has  been  made,  the  part  may  be  poulticed  for 
a  day  or  two,  and  the  abscess  cavity  then  dressed  with  lint, 
care  being  taken  to  keep  the  lips  of  the  incision  separated. 

Another  frequent  cause  of  superficial  abscess  is  the  acute 
inflammation  and  suppuration  of  an  external  hemorrhoid, 
which  generally  comes  on  after  an  attack  of  constipation  and 
straining  at  stool,  or  may  be  due  to  the  same  causes  as  the  last. 
The  suffering  caused  by  such  a  condition,  as  by  the  one  last  de- 
scribed, is  out  of  all  proportion  to  its  apparent  importance,  and 
is  sufficient  to  incapacitate  a  person  of  sensitive  organization 
from  all  accustomed  duties.  The  remains  of  former  external 
haemorrhoids  are  always  liable  to  this  accident,  and  by  the 
proper  abortive  treatment,  the  inflammation  may  sometimes  be 
overcome  without  suppuration.  If,  however,  suppuration  ap- 
pears to  be  inevitable,  a  small  sharp-pointed  bistoury  should  be 
quickly  passed  through  the  little  tumor. 

There  is  also  a  form  of  superficial  abscess  which  lies  nearer 
to  the  mucous  membrane  than  the  skin,  and  is  due  to  the  acute 
inflammation  of  an  internal  hemorrhoid,  either  just  at  the  verge 
of  the  anus  or  within  the  sphincter.  This  is  in  reality  a  circum- 
scribed phlebitis  in  a  venous  pouch  which  is  shut  off  from  the 
general  circulation.  A  circumscribed,  tense,  exquisitely  painful 
tumor  is  formed,  varying  in  size  from  a  grape  to  an  almond, 
which,  after  a  few  days  of  suffering,  ruptures  spontaneously, 
and  allows  the  escape  of  a  small  quantity  of  pus.     Such  an  ab- 


92  DISEASES    OF   THE    RECTUM    AND    ANUS. 

scess,  when  within  the  bowel,  is  always  liable,  as  will  be  shown 
later,  to  result  in  the  formation  of  a  blind  internal  fistula  if  left 
to  its  own  course,  and  should,  therefore,  be  treated  by  early 
incision. 

There  is  still  another  variety  of  superficial  abscess,  more 
serious  in  its  consequences  than  those  already  described,  for 
the  reason  that  it  affects  the  subcutaneous  tissue  and  not  the 
skin,  and  is  diffuse  and  not  circumscribed.  The  causes  of  this 
variety  of  abscess  are  the  same  as  of  those  already  mentioned, 
though  traumatism  plays,  perhaps,  a  more  important  role. 
Falls,  kicks,  horse-back  exercise,  and  violence  in  the  use  of 
the  syringe  are  its  most  frequent  antecedents.  Surgical  inter- 
ference with  the  rectum,  as  in  the  removal  of  a  hemorrhoid, 
may  also  be  followed  by  this  form  of  abscess,  and  it  may  arise 
from  the  perforation  of  the  wall  of  the  bowel  just  above  the 
sphincter,  by  an  ulceration  of  any  kind,  generally,  however, 
that  due  to  a  foreign  body.  It  has  also  been  known  to  follow 
the  suppuration  of  an  internal  hemorrhoid. 

The  symptoms  of  this  form  of  disease  vary  greatly  in  differ- 
ent cases.  In  cachectic  persons,  pus  may  form  in  large  quan- 
tity, and  break  into  the  bowel,  and  a  blind  internal  fistula  may 
result.  The  diagnosis  is  generally  easy.  There  will  be  the 
usual  pain,  tenderness,  and  swelling  ;  and  if  the  pain  be  not  too 
severe  to  admit  of  the  attempt,  fluctuation  may  be  obtained  by 
introducing  one  finger  into  the  rectum,  and  making  counter- 
pressure  with  the  other  hand  outside. 

There  is  little  use  in  hoping  for  resolution  in  an  abscess  of 
this  kind,  and  alL active  attempts  to  cause  it  will  be  found  to 
do  harm,  rather  than  good.  The  proper  treatment  is  an  early 
free  incision.  If  the  incision  be  made  early,  it  may  in  itself 
have  an  abortive  action,  and  under  such  circumstances  it  need 
not  be  very  large.  If  pus  has  already  formed,  or  the  skin  has 
begun  to  grow  thin  over  the  abscess  cavity,  the  incision  should 
be  free  enough  to  allow  of  the  easy  escape  of  the  contents,  for 
in  this  way  only  can  the  formation  of  a  fistula  be  avoided.  In 
such  a  case,  drainage  should  be  resorted  to  after  the  incision, 
and  every  effort  should  be  made  to  secure  healing  from  the 
bottom  of  the  cavity. 

When  the  incision  is  made  in  the  early  stage  of  such  a  tumor 
;i-  this,  while  the  skin  is  yet  hard  and  infiltrated,  a  free  hemor- 
rhage from  cutaneous  vessels  is  not  uncommon,  nor  on  account 


ABSCESS    AND    FISTULA.  93 

of  its  antiphlogistic  action  is  it  to  be  deprecated.  Only  when  it 
has  passed  the  bounds  of  safety  need  any  steps  be  taken  to  ar- 
rest it,  and  this  may  always  be  done  by  a  careful  stuffing  of  the 
incision  with  picked  lint.  A  word  of  caution  against  opening 
such  abscesses  as  these  in  the  surgeon' s  office,  and  allowing  the 
patient  to  walk  home,  may  not  be  out  of  place  ;  for  a  small 
artery  may  commence  spurting  at  any  moment  during  the  ac- 
tive exercise. 

Deep  Abscess. — The  deep  abscesses  of  this  region  differ 
greatly  from  those  already  described,  in  their  location,  extent, 
and  gravity.  They  may  with  advantage  be  divided  into  those 
of  the  ischio-rectal  fossa  and  those  of  the  superior  pelvi-rectal 
space,  which  is  thus  defined  by  Richet.1     See  Fig.  65. 

"The  superior  pelvi-rectal  space,  contained  between  the 
superior  aponeurosis  of  the  levator,  the  peritoneum,  the  rec- 
tum, and  the  walls  of  the  pelvis,  has  a  variable  extent  in  dif- 
ferent subjects,  and  especially  varies  according  as  the  levator  is 
or  is  not  relaxed.  Its  greatest  extent  is  reached  when  the  mus- 
cle is  in  repose.  In  this  condition  the  levator  in  its  upper  part 
is  in  contact  with  the  ischiatic  walls,  the  lower  end  of  the  rec- 
tum is  much  lowered,  and  the  summit  of  the  inf  undibulum  is  as 
distant  as  possible  from  the  peritoneum  ;  while  the  contractions 
of  the  muscle  efface  the  rectal  funnel  and  approach  it  to  the 
point  of  reflexion  of  the  peritoneum.  At  its  anterior  part  the 
pelvi-rectal  space  is  much  less  extensive  than  at  the  sides  and 
especially  behind,  which  is  due  to  two  causes  ;  the  first  is  that 
the  peritoneum,  which  is  much  lowered  in  front  of  the  rectum  to 
form  the  recto-vesical  cul-de-sac,  gradually  rises  behind  to  meet 
the  sacrum  ;  the  second  is  that  the  plane  formed  by  the  levator 
inclines  in  a  reverse  direction  to  the  former,  that  is  from  the 
prostate  to  the  coccyx.  Therefore  these  two  planes  are  sepa- 
rated in  front  by  scarcely  a  few  millimetres,  while  behind  they 
are  several  centimetres  apart.  An  abundant  cellular  tissue  with 
large  and  lax  meshes  fills  the  whole  space,  and  seems  intended 
to  favor  the  movement  and  expansion  of  the  rectum  ;  rarely  it 
is  loaded  with  fat.  In  front  and  laterally  this  tissue  communi- 
cates with  that  which  fills  the  iliac  fossae  and  the  deeper  regions 
of  the  abdomen  through  the  intervention  of  the  subperitoneal 
cellular  layer  of  the  pelvic  walls,  and,  in  women,  it  is  continu- 

1  Traito  d.  Anat.  Med.  Ohir.,  8d  Edit.,  p.  82S. 


94  DISEASES    OF    THE   RECTUM    AND    ANUS. 

ous  with  that  of  the  broad  ligament ;  behind  it  is  continu- 
ous with  that  found  in  the  meso-rectum  and  the  concavity 
of  the  sacrum,  and  it  communicates  with  the  gluteal  region  by 
the  sciatic  notch.  It  is  traversed  by  the  visceral  branches  of 
the  hypogastric  artery  and  vein  ;  the  sacral  plexus,  and  the 
ganglia  of  the  great  sympathetic  against  the  sacrum,  are  cov- 
ered by  it. 

4 'In  men  the  superior  pelvi-rectal  space  is  separated  from 
the  prostate,  the  seminal  vesicles,  and  the  bas-fond  of  the 
bladder  by  a  cellulo-fibrous  layer  called  prostato-peritoneal. 
In  women  it  may  be  said  not  to  exist  anteriorly,  because  the 
rectum  is  applied  without  intervention  to  the  posterior  wall  of 
the  vagina.1' 

An  abscess  of  the  ischio-rectal  fossa  is  generally  bounded  by 
the  levator  ani  muscle  superiorly,  and  by  the  skin  below,  with 
the  rectum  on  one  side,  and  the  adjacent  portion  of  the  pelvis 
on  the  other.  An  abscess  of  the  superior  pelvi-rectal  space,  on 
the  other  hand,  originates  in  the  lax  connective  tissue  around 
the  upper  portion  of  the  rectum  above  the  levator  ani  muscle. 
It  may  assume  vast  proportions,  blending  laterally  with  the 
subperitoneal  connective  tissue  of  the  iliac  fossa,  and  burrowing 
in  almost  any  direction  in  the  true  pelvis. 

The  causes  of  deep  rectal  abscesses  are  various.  Trauma- 
tism is  perhaps  the  most  frequent,  and  the  injury  is  generally 
internal,  rather  than  external,  and  is  caused  by  the  point  of  a 
syringe  or  a  foreign  body,  rather  than  by  kicks  and  falls.  For- 
eign bodies,  such  as  fish-bones,  may  pass  entirely  through  the 
rectal  wall,  and  be  found  loose  in  the  cavity  of  the  abscess  they 
have  caused.  Such  an  abscess  may  also  be  due  to  the  injury 
inflicted  by  the  fcetal  head  in  parturition,  and  in  such  a  case, 
the  diagnosis  may  be  difficult  to  make  from  a  puerperal  inflam- 
mation due  to  blood-poisoning  and  involvement  of  the  lym- 
phatics. They  may  also  be  secondary  to  diseases  of  the  urinary 
organs,  such  as  acute  inflammation  of  the  prostate,  or  a  rupture 
of  the  urethra,  and  extravasation  of  urine  ;  and  they  may  result 
from  rupture,  ulceration,  or  perforation  of  the  rectal  wall,  in 
connection  with  stricture. 

Tli is  explains  partly,  though  not  completely,  the  frequent 
coexistence  of  stricture  and  numerous  fistula?,  for  a  stricture 
may  act  as  the  exciting  cause  of  a  deep  abscess  by  the  impair- 
ment of  vitality  and  nutrition  which  it  causes,  as  well  as  by 


ABSCESS    AND    FISTULA.  95 

producing  a  perforating  ulcer  above,  as  is  proven  by  the  fact 
that  a  great  many  fistulse  have  their  internal  openings  below, 
and  not  above  the  constriction. 

Again,  these  abscesses  may  be  due  to  a  submucous  inflam- 
mation, and  production  of  pus,  which  first  breaks  into  the  rec- 
tum, and  forms  an  internal  fistula,  and  subsequently  extends 
outward,  forming  a  large  abscess ;  or  they  may  be  due  to  an 
acute  phlebitis,  or  to  faulty  nutrition  and  a  generally  vitiated 
state.  Finally,  they  may  be  in  their  origin  entirely  discon- 
nected with  the  rectum,  and  due  to  disease  of  some  neighboring 
part,  or  to  necrosis  of  some  adjacent  bone  of  the  pelvis  or  spine. 
In  the  latter  case  they  are  generally  of  the  variety  known  as 
cold  abscess,  and  are  apt  to  be  preceded  for  a  long  time  by  pain 
at  the  point  of  disease  in  the  bone. 

Finally,  for  lack  of  any  known  cause  we  are  compelled  to 
consider  some  of  them  as  idiopathic,  originating  in  an  acute 
inflammation  of  the  cellular  tissue  of  the  superior  pelvi-rectal 
space.  These  generally  form  behind  the  rectum,  where  the 
space  is  the  largest,  and  are  attended  by  the  formation  of  abun- 
dance of  pus  and  gas,  the  latter  being  due  to  the  decomposition 
of  the  pus  and  not  to  communication  with  the  rectum.  The 
inflammation  may  also  have  its  point  of  origin  in  or  around  the 
prostate,  and  the  abscess  is  then  described  as  prostatic  or 
peri-prostatic. 

There  is  still  another  variety  of  abscess,  which  occasionally 
occurs  around  the  anus,  and  which  has  been  very  appropriately 
named  by  Paget  the  "Residual  Abscess."  It  is  an  abscess 
arising  in  an  old  cicatrix.  The  following  case  is  a  good  example 
of  this  form  of  disease. 

Case.     Residual  Abscess. — J.  D ,  aged  forty-five.     The 

patient  was  a  large,  fleshy  man,  who  was  operated  upon  by  me 
for  fistula,  with  a  good  result,  in  June,  1882.  The  track  was 
deep,  but  the  wound  healed  kindly,  leaving  a  deep  cicatrix. 

In  December  of  the  same  year,  after  an  interval  of  several 
months  of  health,  he  applied  to  me  again  for  pain  at  the  seat  of 
the  former  incision.  An  examination  showed  a  puffy  swelling 
of  the  old  cicatrix,  with  a  decidedly  erysipelatous  blush  and  a 
brawny  swelling  extending  for  a  considerable  distance  over  the 
buttock.  An  incision  was  at  once  made  into  the  centre  of  this 
over  the  cicatrix,  and  a  quantity  of  serous  fluid  was  evacuated. 
The  patient  was  confined  to  bed  for  a  few  days,  the  bowels 


06  DISEASES    OF    THE    RECTUM    AND    ANUS. 

were  freely  moved  with  a  cathartic,  and  a  lotion  of  lead  and 
opium  applied  to  the  part,  and  in  a  few  days  the  trouble  had 
disappeared.  He  still,  however,  complains  of  an  occasional 
tenderness  in  the  part,  though  another  year  has  elapsed. 

Symptoms. — In  an  abscess  of  the  superior  pelvi-rectal  space 
the  symptoms  are  often  obscure  and  far  from  characteristic. 
There  is  more  or  less  vague  pain  in  the  pelvis  and  lumbar 
region,  which  is  seldom  intense  and  is  generally  increased  in 
defecation.  Fever  may  be  entirely  absent,  is  seldom  continu- 
ous, and  chills  are  only  occasionally  met  with  when  pus  is 
formed.  In  addition  there  is  more  or  less  headache  and  general 
malaise,  and  the  vesical  symptoms  (retention  and  incontinence 
of  urine)  are  apt  to  be  marked. 

The  following  cases  will  serve  to  illustrate  the  general  char- 
acter and  course  of  the  disease. 

Case.    Abscess  of  the  Superior  Pelvi-rectal  Space  opening 

into  the  Bladder. — Dr.    M ,  aged  fifty- three.      The  patient 

was  in  his  usual  good  health  until  the  morning  of  April  3d, 
when  he  experienced  some  pain  in  the  rectum  and  some  diffi- 
culty in  micturition,  with  pain  in  the  act,  and  frequency  in  the 
desire.  This  pain  was  shortly  followed  by  a  chill  and  high 
fever,  the  temperature  reaching  103°  F.,  and  the  pulse  120. 
The  fever  and  pain  lasted  about  one  week,  at  the  end  of  which, 
the  difficulty  in  urination  had  become  so  great  that  he  was 
obliged  to  use  the  catheter  upon  himself  for  one  day.  During 
this  time  he  was  also  suffering  greatly  from  constipation,  and 
was  forced  to  use  cathartics  and  enemata  to  induce  a  motion. 
He  also  noticed  that  when  the  enemata  were  ejected  they  were 
always  squirted  off  toward  the  right  side  and  expelled  with  a 
violent  spasmodic  action.  The  pain  had  also  become  distinctly 
localized  in  the  left  side  of  the  pelvis  and  near  the  bladder. 

Three  weeks  from  the  time  of  the  first  chill  he  passed  a  large 
quantity  of  pus  from  the  bladder.  The  discharge  was  very  free, 
amounted  to  many  ounces,  and  lasted,  with  each  act  of  urin- 
ation, for  three  days,  after  which  it  ceased  entirely.  After  a 
short  interval  he  began  again  to  have  fever  and  chills  with  the 
same  rectal  and  vesical  symptoms,  and  after  two  weeks  of 
suffering  there  was  another  discharge  of  pus  by  the  urethra, 
which  this  time  lasted  four  days  and  then  began  to  diminish 
gradually,  so  that  at  the  end  of  six  weeks  it  had  again  ceased. 
He  had  never  recognized  pus  in   the  faeces,   but  there  was 


ABSCESS    AND    FISTULA.  97 

much  mucus,  and  once  something  that  seemed  to  him  like  a 
slough. 

An  examination  showed  an  indurated  mass  on  the  left  side 
of  the  rectum,  above  and  to  the  left  of  the  prostate,  which  was 
not  enlarged.  This  mass  was  painful  to  the  touch,  but  I  could 
not  decide  that  it  contained  pus  to  any  considerable  amount. 
The  patient  was  pale  and  thin,  and  showed  the  effects  of  the 
sickness  and  suffering  ;  but  as  there  was  no  indication  for  opera- 
tive interference  with  the  cure  nature  seemed  to  be  effecting,  I 
advised  him  to  spend  some  time  at  the  sea-shore  and  await 
further  developments. 

A  week  later  the  patient  brought  me  some  long  shreds  of 
tenaceous  mucus  which  he  was  in  the  habit  of  passing  from  the 
bowel.  He  locates  most  of  his  pain  up  under  the  rami  of  the 
pubes,  and  says  that  at  times  it  is  of  that  peculiar  sickening 
character  which  comes  when  the  testicle  is  wounded.  Another 
examination  was  made  but  revealed,  nothing  new.  The  tender- 
ness was  at  a  point  three  or  four  inches  from  the  anus  on  the 
left  lateral  wall  of  the  bowel,  and  at  this  point  there  seemed  to 
be  a  central  softening  in  the  induration.  He  was  advised  to 
continue  the  same  plan  of  treatment,  which  consisted  in  rest, 
change  of  air,  laxatives,  nourishing  food,  and  suppositories  of 
belladonna  and  iodoform  ;  and  about  a  fortnight  later  he  found 
himself  greatly  improved,  and  went  on  from  that  time  to  a 
complete  recovery. 

Case.  Abscess  in  the  Pelvis. — Boy,  aged  twelve  ;  slight  and 
of  delicate  build,  but  generally  well.  Has  had  pain  in  the  abdo- 
men for  the  last  forty -eight  hours.  Pain  on  urination  and  de- 
fecation, and  tenderness  all  over  the  lower  part  of  the  bowels, 
but  without  localization  at  any  one  point.  Temperature  103°  F. 
Pulse  130.     Two  soft  evacuations  from  bowels  yesterday. 

Next  day  (third  of  disease)  he  "thought  it  hurt  him  more 
on  the  right  side  than  on  the  left  when  he  tried  to  stand  up," 
and  there  was  some  dulness  in  the  right  fossa  but  no  swelling. 
Has  vomited  his  milk  once. 

Fourth  day.  Temperature  has  continued  to  range  between 
101°  in  the  morning,  and  103°  in  the  afternoon.  Passed  a  very 
restless  night  and  begins  to  show  signs  of  suffering.  There  is 
flatulence,  but  not  as  much  distention  of  the  abdomen  ;  vomit- 
ing and  vesical  tenesmus  continue.  Has  had  no  chill.  The 
tenderness  is  now  confined  to  the  right  fossa,  and  is  greatest  at 

7 


98  DISEASES    OF    THE    KECTTTM    AND    ANUS. 

a  point  half-way  between  the  anterior  superior  spine  and  the 
pubes,  and  above  a  line  running  from  one  anterior  superior 
spine  to  the  other,  where  a  slight  tumefaction  can  be  made  out 
by  careful  palpation.  ~No  superficial  redness.  Bowels  have  not 
moved  since  the  first  day.  On  consultation  with  Drs.  Sabine 
and  Bullard  it  was  decided  that  an  operation  was  not  immedi- 
ately indicated,  and  the  same  treatment,  quinia,  morphia,  wine, 
and  fluid  diet  was  continued. 

Sixth  day.  Marked  relief  of  all  symptoms ;  less  pain,  less 
tenderness,  four  free  fluid  evacuations  from  the  bowels  in  rapid 
succession,  fall  in  temperature  and  pulse,  appetite  better,  and 
had  a  good  night's  sleep. 

From  the  sixth  to  the  thirteenth  day  there  was  little  change. 
The  bowels  moved  daily,  but  always  with  more  or  less  pain,  and 
the  appetite  and  strength  returned  in  a  measure,  so  that  he  was 
able  to  leave  his  bed.  But  the  temperature  daily  showed  the 
same  increase  above  the  normal,  never  falling  below  100°  ;  and 
the  pain  and  tenderness  did  not  diminish.  For  a  day  or  two 
the  parents  had  remarked  a  peculiar  bubbling  noise,  which  they 
heard  at  times  at  the  seat  of  the  tumor,  and  on  the  twelfth  day 
a  part  of  the  dulness  was  found  replaced  by  clear  tympanitic 
resonance,  and  the  diagnosis  of  a  communication  between  the 
rectum  and  the  tumor  was  made.  On  the  thirteenth  day  he 
had  a  very  free,  fluid,  and  offensive  discharge  from  the  bowels, 
which  the  parents  said  contained  pus,  followed  by  a  marked  fall 
in  temperature  and  diminution  in  the  pain  ;  and  for  the  next 
two  days  he  was  comparatively  comfortable. 

Sixteenth  day,  evening.  Complaining  of  great  pain,  rolling 
and  tossing  in  bed,  and  screaming  with  agony.  Found  him 
lying  on  his  right  side,  legs  drawn  up,  sphincter  ani  relaxed, 
mucous  membrane  slightly  protruding,  and  a  small  stream  of 
clear  mucus  flowing  from  the  anus,  and  staining  the  bed.  The 
rectal  tenesmus  was  very  great.  He  had  passed  a  small  amount 
of  faeces  during  the  morning,  and  had  passed  most  of  the  day 
sitting  up  in  bed,  enjoying  his  supposed  convalescence. 

Digital  examination  of  the  rectum  revealed  a  hard  tumor 
pressing  upon  and  almost  closing  it,  situated  on  the  anterior 
wall,  to  the  right,  and  above  the  prostate.  Large  dose  of  mor- 
phia given  to  quiet  him  during  the  night. 

At  my  visit  next  morning  he  was  more  comfortable,  and  the 
tenesmus  had  in  part  ceased.     Had  passed  nothing  per  rectum. 


ABSCESS    AND    FISTULA.  99 

On  turning  him  on  his  back  I  was  surprised  to  see  what  ap- 
peared to  be  a  greatly  distended  bladder  reaching  nearly  to  the 
umbilicus  and  plainly  outlined  against  the  abdominal  wall.  He 
had  passed  his  water  twice  during  the  night,  he  said,  and  was 
not  suffering  from  any  desire  to  do  so.  Stupes  over  the  abdo- 
men brought  away  only  four  ounces  of  urine  (by  measure)  and 
caused  the  entire  disappearance  of  the  visible  tumor.  The  dul- 
ness  and  the  hardness  to  the  touch  still  remained,  however,  and 
extended  half-way  from  the  pubes  to  the  umbilicus.  Under 
ether  he  was  catheterized  and  three  more  ounces  of  urine  with- 
drawn, thus  entirely  emptying  the  bladder,  but  causing  no 
change  in  the  tumor,  which  occupied  the  place  usually  occupied 
by  a  distended  bladder. 

By  careful  examination  the  following  condition  was  then 
made  out :  A  firm,  hard  tumor  in  the  pelvis  toward  the  right 
side,  the  upper  edge  of  which  could  be  felt  by  deep  pressure 
about  half-way  between  the  pubes  and  the  umbilicus,  and  the 
lower  surface  of  which  could  be  felt  with  the  finger  in  the  rec- 
tum. The  pressure  upon  the  rectum  was  nearly  sufficient  to  oc- 
clude it,  and  it  was  with  difficulty  that  the  limit  of  the  tumor 
above  could  be  made  out  in  this  way.  The  mass  could  not  be 
made  to  fluctuate  by  this  conjoined  manipulation.  A  medium 
sized  aspirator  needle  was  thrust  into  the  tumor  from  the  ab- 
dominal wall,  and  a  pint  of  fetid,  greenish  pus  evacuated.  The 
point  of  the  needle  was  then  used  as  a  director,  and  could  be 
felt  by  the  finger  in  the  rectum.  It  was  cut  down  upon  from 
the  rectum  and  a  free  vent  allowed  for  the  contents  of  the  ab- 
scess in  this  way  at  its  most  dependent  portion.  The  end  of  the 
index  finger  passed  through  this  incision  into  a  large  abscess 
cavity,  the  limits  of  which  could  not  be  determined. 

By  a  daily  introduction  of  the  index  finger  into  the  incision 
it  was  kept  open;  more  or  less  pus  was  evacuated  in  the  stools 
for  some  time,  and  the  abscess  finally  healed  very  kindly.  One 
year  after  the  operation  the  boy  was  still  in  perfect  health. 

An  abscess  of  the  ischio-rectal  fossa  may  at  its  commence- 
ment be  accompanied  by  the  same  symptoms  as  one  in  the 
pelvi-rectal  space,  but  later,  the  skin  becomes  hard,  red,  and 
cedematous  sometimes  over  a  large  portion  of  the  corresponding 
buttock,  the  pain  is  very  severe,  and  rectal  touch  impossible. 
The  general  symptoms  are  those  of  any  acute  inflammation.  In 
abscess  of  the  superior  pelvi-rectal  space,  when  the  disease  has 


100  DISEASES    OF    THE    EECTUM    AND    ANUS. 

extended  to  the  cellular  tissue  of  the  iliac  fossa,  immense  col- 
lections of  pus  may  form,  and  this  may  burrow  in  any  direc- 
tion. In  men  it  generally  follows  the  course  of  the  bowel,  in- 
volves secondarily  the  ischio-rectal  fossa,  and  makes  its  way 
through  the  skin  at  some  distance  from  the  anus.  In  women  it 
is  more  apt  to  pursue  a  contrary  direction,  and  may  appear  on 
the  surface  in  the  region  of  the  crest  of  the  ilium  or  in  the  groin. 
An  abscess  of  the  ischio-rectal  fossa  may  tend  to  discharge  its 
contents  upward  toward  the  superior  perineal  region,  being  less 
confined  by  fascia  and  muscle  in  this  direction.  In  this  way 
the  prostate  and  urethra  may  be  implicated,  and  the  signs  of 
retention  of  urine  may  be  joined  with  those  which  point  more 
directly  to  the  rectum. 

The  pus  from  such  an  abscess,  in  time,  generally  breaks  on 
the  cutaneous  surface  and  forms  one  or  several  permanent  fistu- 
lous tracks.  The  pus  from  a  pelvi-rectal  abscess  not  infre- 
quently makes  its  way  into  the  rectum  and  is  discharged  with 
each  act  of  defecation ;  before  the  faeces  when  the  opening  is 
near  the  anus,  after  them  when  it  is  above  the  rectal  pouch.  It 
may,  however,  rupture  into  the  vagina,  bladder,  uterus,  or  per- 
itoneum, but  these  internal  openings  are  not  the  rule,  but  the 
exception,  for  the  pus  generally  finds  its  way  to  the  cutaneous 
surface,  and  fistula?  result  as  with  ischio-rectal  abscesses. 
Either  variety  may  cause  fistulous  tracks  upward  into  the  true 
pelvis,  downward  into  the  perineum,  or  outward  into  the  thigh. 
When  the  pus  reaches  the  rectum  it  may  burrow  for  a  consid- 
erable distance  in  the  submucous  connective  tissue  of  the  bowel, 
and  separate  the  mucous  membrane  from  its  attachment  before 
perforating  it.  In  this  way  two  large  abscess  cavities  may  be 
formed  communicating  with  each  other  by  a  narrow  orifice. 

What  is  now  generally  known  as  the  horse-shoe  abscess  or 
fistula  is  due  to  the  formation  of  an  abscess  in  each  fossa  and 
the  communication  of  the  two  behind  the  rectum  through  the 
substance  of  the  sphincter  muscle  at  its  attachment  to  the 
coccyx.  Such  an  abscess  generally  has  one  opening  into  the 
bowel  and  two  on  the  cutaneous  surface,  though  the  latter  may 
be  single  also.  By  manipulation  the  pus  may  be  made  to  cross 
from  one  fossa  to  the  other,  imparting  a  characteristic  sense  of 
fluctuation. 

There  is  a  form  of  gangrenous  cellulitis  which  sometimes  af- 
fects the  ischio-rectal  region.     It  is  a  rare  disease,  and  is  gen- 


ABSCESS    AND    FISTULA.  101 

erally  idiopathic.  In  it  there  is  no  pus  formed,  but  the  cellular 
tissue  and  the  skin  over  it  become  necrosed  and  slough  in  large, 
black  masses.  The  adjacent  portion  of  the  rectal  wall  may  be 
involved  and  the  rectum  be  laid  open  for  a  considerable  extent. 
The  disease  is  attended  with  fever  and  great  prostration ;  the 
tendency  to  relapse  and  extension  is  marked,  and  the  cavity 
left  after  separation  of  the  slough  closes  very  slowly.1  This 
form  of  disease  may  be  fatal. 

The  reasons  why  abscesses  in  this  region  so  seldom  heal 
spontaneously  are  to  be  found  in  the  anatomy  of  the  part,  and 
the  fixedness  or  mobility  of  the  walls  of  the  abscess  cavity.  In 
the  ischio-rectal  variety  the  skin  is  hard,  thickened  and  larda- 
ceous,  and  from  its  rigidity  cannot  yield  its  position  to  allow  of 
healing.  The  walls  of  the  abscess  higher  up  in  the  pelvi-rectal 
space,  on  the  contra^,  move  with  the  varying  fulness  of  the  ab- 
dominal or  pelvic  organs,  with  the  incessant  action  of  the  levator 
ani,  and  with  the  fulness  or  vacuity  of  the  abscess  cavity, 
which  depends  on  the  intermittent  discharge  of  pus  through  its 
small  opening. 

Diagnosis. — The  diagnosis  of  these  conditions  should  be 
made  with  great  care,  for  on  a  correct  appreciation  of  the  ex- 
tent of  the  disease  will  depend  the  prognosis  and  treatment ; 
and  the  class  of  fistulse  resulting  from  these  deep  abscesses  re- 
quires careful  treatment,  and  may  not  always  be  suitable  for 
any  operative  interference. 

An  abscess  in  the  ischio-rectal  fossa  will  generally  be  mani- 
fest to  any  one  making  a  careful  examination  of  the  parts  and 
giving  heed  to  the  history,  but  one  in  the  pelvi-rectal  space  can 
generally  only  be  suspected  from  the  history  and  found  only  by 
careful  pelvic  examination.  The  finger  in  the  rectum  may  make 
the  whole  case  plain,  or  the  inflammatory  hardness  and  tender- 
ness may  be  more  manifest  by  deep  pressure  through  the  ab- 
dominal parietes. 

1  A  Clinical  Lecture  on  Idiopathic  Gangrenous  Cellulitis  around  the  Rectum.  Fur- 
neaux  Jordan,  Brit.  Med.  Jour.,  January  18,  1879.  Also,  Jackson,  Brit.  Med.  Jour., 
February  8,  1879.  This  disease  is  apparently  the  same  as  that  denned  by  Dunglison 
under  the  head  of  Proctocace  (Proctitis  Gangrenosa,  Mastdarmfiiule,  Cacoproctia)  and 
so  named  by  Fuchs.  "  According  to  him  (Fuchs)  it  is  common  in  Peru,  in  the  neigh- 
borhood of  Quito  and  Lima,  on  the  Honduras  and  Mosquito  coasts,  in  Brazil,  and  on 
the  Gold  coast.  It  is  called  by  the  Portuguese  Bicho  and  Bicho  di  Culo  ;  by  the  peo- 
ple of  Quito,  Mai  del  Valle,  from  its  prevalence  in  the  valleys ;  and  in  Africa,  Bitios 
de  Kis.  It  is  an  adynamic,  inflammatory  condition,  frequently  ending  in  gangrene. 
It  has  been  attributed  to  bad  food  and  the  use  of  spices."  -Dunglison. 


1M2  DISEASES    OE    THE    RECTUM    AND    ANUS. 

A  fistulous  track  communicating  with  a  pelvi-rectal  abscess 
may  generally  be  recognized  by  its  length  and  by  the  amount 
of  tissue  between  it  and  the  bowel,  which  may  easily  be  esti- 
mated with  one  ringer  in  the  rectum  and  a  probe  in  the  track. 
The  probe  does  not  approach  the  rectum,  but  either  runs  par- 
allel with  it.  or  recedes  from  it.  The  now  of  pus  from  the 
opening  is  also  apt  to  be  intermittent  and  to  occur  at  the  time 
of  defecation,  being  caused  by  the  same  muscular  effort.  Some- 
times, when  the  cavity  has  not  been  recently  emptied,  a  soft 
tumor  may  be  felt  by  rectal  touch,  and  pressure  upon  it  may 
cause  a  How  of  pus.  With  the  pus  bubbles  of  gas  may  also 
appear,  but  in  a  large  abscess  in  the  neighborhood  of  the  bowel 
this  is  not  a  proof  of  an  internal  opening,  but  may  be  due 
merely  to  the  proximity  of  the  intestine. 

Prognosis. — The  prognosis  is  necessarily  grave.  In  the  be- 
ginning the  patient  is  exposed  to  all  the  dangers  of  pyaemia, 
peritonitis,  and  phlebitis  :  and  should  the  abscess  go  on  to  a 
favorable  termination  in  an  external  opening,  there  is  still  the 
dread  that  it  may  at  any  time  seek  another  opening  toward  the 
peritoneum  with  a  fatal  result.  The  immediate  results  being 
favorable,  the  ultimate  ones  may  still  be  disastrous  :  beinsr 
those  which  always  attend  upon  prolonged  suppuration — vis- 
ceral complications,  amyloid  degeneration  of  the  liver  and  kid- 
D  jys,  and  tubercular  deposits.  In  the  comparatively  small 
number  of  cases  of  pelvi-rectal  abscess  in  which  healing  occurs. 
the  patient  still  has  to  meet  the  results  of  extensive  cicatricial 
contraction.  These  may  be  stricture  on  the  one  hand,  or  incon- 
tinence on  the  other  :  with  the  subacute  inflammatory  tendency 
which  is  always  apt  to  attend  upon  a  cicatrix  at  the  anus  and 
cause  p>ain  and  uneasiness.  In  females  especially,  such  a  cica- 
trix may  be  the  cause  of  grave  trouble  with  the  genito-nrinary 
canal. 

Treat  in'- nt. — It  may  be  considered  as  a  rule  to  which  there 
are  few  exceptions,  that  an  acute  inflammation  in  this  region 
will  go  on  to  suppuration  :  and  hence  that  antiphlogistic  meas- 
adopted  with  a  view  to  securing  resolution  are  useless. 
Early  incision  is.  therefore,  the  only  rational  treatment,  and, 
where  properly  performed,  this  may  result  in  cure  without  the 
formation  of  fistula,  as  is  illustrated  in  the  following  case. 

<     -k.     IscMo-Hectal  Abscess  treated  by  Marly  Incision 
and  cured  without  the  Formation  of  a  Fistula- — The  patient. 


ABSCESS    AND    FISTULA.  103 

a  professional  man,  aged  thirty-seven  years,  had  been  suffering 
for  several  years  from  large  internal  haemorrhoids  which  bled 
freely.  For  some  weeks  before  sending  for  me  he  had  been 
under  the  care  of  an  irregular  specialist,  who  had  been  follow- 
ing out  some  plan  of  local  treatment  for  this  condition,  the  na- 
ture of  which  the  patient  did  not  understand.  Although  there 
was  some  decrease  in  the  amount  of  blood  lost,  his  general  con- 
dition became  far  from  satisfactory.  Though  naturally  a  large, 
healthy  man,  and  accustomed  to  hard  mental  work  and  abund- 
ant exercise,  he  began  to  suffer  from  lassitude,  loss  of  appetite, 
and  emaciation.  Finally,  a  hard  mass  was  felt  in  the  right 
ischio-rectal  fossa,  which  caused  him  a  good  deal  of  pain,  and 
after  this  had  lasted  five  days  he  sent  for  me. 

Examination. — A  hard,  brawny,  painful  swelling  completely 
filled  the  right  fossa.  The  skin  over  it  was  red  and  hot,  but 
there  was  no  fluctuation.  There  had  been  a  chill,  some  fever, 
and  complete  loss  of  appetite,  with  a  good  deal  of  rectal  te- 
nesmus. 

Operation. — The  patient  was  etherized,  and  a  deep  incision 
made  into  the  swelling.  Although  the  cut  was  made  over  the 
most  prominent  portion  of  the  mass,  it  failed  to  reach  pus, 
being  too  far  out  upon  the  buttock.  A  longer,  straight  knife 
was  again  entered  within  half  an  inch  of  the  margin  of  the  anus 
and  carried  steadily  upward,  parallel  with  the  bowel,  about 
four  inches.  The  blade  was  turned  in  its  track  occasionally  as 
it  was  entered,  to  allow  of  the  escape  of  pus  as  soon  as  it  was 
reached,  but  none  appeared  till  the  depth  mentioned  was  ar- 
rived at.  After  pus  was  found,  the  knife  was  withdrawn, 
making  an  incision  fully  three  inches  long  at  the  surface,  in  an 
antero-posterior  direction.  Into  the  opening  thus  made  the 
finger  was  passed  till  it  reached  the  abscess  cavity,  and  all  par- 
titions were  broken  down.  This  part  of  the  work  was  done 
very  thoroughly,  and  the  original  incision  was  made  still  longer, 
so  that  future  burrowing  might  be  avoided.  A  solution  of  car- 
bolic acid  was  then  injected  into  all  parts  of  the  wound,  and 
the  cavity  was  dressed  with  lint  soaked  in  carbolized  oil  (1-12). 
After  this  the  sphincter  was  dilated,  and  several  large  haemor- 
rhoidal  tumors  were  removed.  The  dressing  thus  introduced 
was  allowed  to  remain  undisturbed  for  three  days,  when  it  was 
removed  and  a  similar  one  replaced,  after  a  thorough  washing 
out  of  the  wound  and  the  introduction  of  the  finger  into  all 


104  DISEASES    OF    THE    EECTUM    AND    ANUS. 

parts  of  it.  The  patient  was  kept  strictly  in  bed,  and  the 
bowels  confined  for  one  week  with  medicine,  at  the  end  of 
which  time  they  moved  easily  and  painlessly  after  a  dose  of 
salts. 

The  operation  was  performed  July  5th.  On  September  15th 
he  was  entirely  well,  the  wound  having  completely  closed. 
This  time  might  have  been  shortened  a  good  deal  had  the  pa- 
tient not  been  obliged  to  be  up  and  about  his  business  during 
the  latter  part  of  the  time  the  wound  was  healing.  He  was  seen 
two  months  later,  and  was  "as  well  as  he  had  ever  been  in  his 
life.'' 

This  case  illustrates  exceedingly  well  several  points  in  rectal 
surgery.  As  to  the  causation  of  the  abscess,  it  cannot  be  posi- 
tively stated  whether  it  was  the  result  merely  of  his  general 
depreciated  condition,  whether  it  was  the  result  of  direct  injury 
while  undergoing  some  secret  treatment  for  haemorrhoids,  or 
whether  it  was  purely  idiopathic.  Whatever  its  cause,  the 
condition  was  one  which  certainly  would  have  ended  in  a  deep 
fistulous  track  opening  high  up  into  the  rectum,  above  the  in- 
ternal sphincter,  had  not  this  particular  operation  been  per- 
formed. It  is  safe  to  say  that  had  this  abscess  been  left  to  its 
own  course,  or  had  it  been  opened  in  the  usual  way — that  is,  by 
making  an  incision  just  large  enough  to  fairly  evacuate  its  con- 
tents— the  subsequent  history  of  the  case  would  have  been  en- 
tirely different.  The  case  is  one  of  a  class  which,  left  to  the 
course  of  nature,  often  work  irreparable  injury — injury  which 
may  render  the  patient's  whole  subsequent  life  one  of  suffering 
in  spite  of  any  future  surgical  procedures — and  yet,  if  treated 
promptly  and  efficiently,  may  be  brought  to  a  very  happy  ter- 
mination. It  is  the  kind  of  case  in  which  a  single  day's  delay 
may  be  ruinous  to  the  interests  of  the  patient. 

In  general  terms  the  incision  should  radiate  from  the  anus 
to  avoid,  as  far  as  possible,  the  section  of  nerves  ;  and  should 
be  free  enough  to  secure  the  escape  of  pus,  not  only  at  the  time, 
but  while  the  abscess  is  healing.  If  there  be  burrowing  in  any 
direction,  the  incision  should  be  prolonged  to  correspond  ;  and 
the  finger  should  be  passed  as  far  as  possible  into  all  parts  of 
the  cavity  to  break  down  all  partitions.  The  wound  should 
then  !)"•  stuffed  with  lint  wet  with  carbolized  oil,  and  a  drainage- 
tube  inserted.  The  secret  of  success  will  be  found  to  lie  in 
securing  a  free  outlet  for  pus,  and  thus  preventing  burrowing. 


ABSCESS    AND    FISTULA.  105 

These  abscesses  should  not  be  laid  open  into  the  rectum — a 
point  which  is  generally  misunderstood  in  practice,  because  of 
the  confounding  of  an  abscess  which  may  ultimately  result  in  a 
fistula  with  fistula  itself.  The  treatment  is  that  of  abscess,  and 
not  that  of  fistula,  and  is  especially  directed  toward  the  preven- 
tion of  fistula. 

Should  the  abscess  have  been  neglected  till  it  has  opened 
externally,  it  is  still  essentially  an  abscess  and  not  a  fistula, 
and  the  treatment  described  may  still  be  carried  out  with  a  fair 
prospect  of  success  in  avoiding  an  opening  into  the  bowel  ;  and 
even  should  the  abscess  have  already  opened  into  the  bowel, 
healing  may  still  be  secured  in  this  way,  with  suitable  means 
for  keeping  the  rectum  empty,  and  a  laying  open  of  the  lower 
end  of  the  rectum  may  be  avoided.  I  wish  to  emphasize  this 
point  strongly,  for  I  have  seen  very  unfortunate  results  follow 
free  division  of  both  sphincters  for  deep  fistulse,  and  it  is  a  step 
which  should  always  be  avoided  if  possible.  That  it  is  possible 
in  this  class  of  cases  I  have  occasionally  proved  to  my  own 
satisfaction,  and  I  do  not  hesitate  now  to  try  every  means  with 
which  I  am  acquainted,  at  any  cost  of  time  to  the  patient,  be- 
fore resorting  to  the  usual  plan  of  dividing  everything  between 
the  track  and  the  bowel. 

When  incontinence  has  resulted  the  case  is  not  to  be  con- 
sidered as  beyond  the  reach  of  help.  I  have  seen  marked 
benefit  result  in  this  sad  condition  from  the  persistent  use  of 
bougies  and  such  other  measures  as  are  calculated  to  increase 
the  power  of  the  sphincters  ;  and  I  am  much  less  inclined  to 
despair  of  being  able  to  afford  relief  in  these  cases  than  formerly. 
In  the  following  case  I  tried  a  novel  procedure  for  the  relief  of 
this  condition  with  a  very  satisfactory  result. 

Case.  Operation  for  the  Relief  of  Incontinence  of  Fceces. — 
The  patient  a  man,  aged  twenty-seven,  was  originally  sent  to 
me  two  years  ago  by  Dr.  McCready,  suffering  from  ischio-rectal 
abscess.  Although  this  was  at  once  operated  upon,  it  did  not 
stop  the  burrowing  of  pus,  and  eventually  a  fistula  was  formed, 
opening  into  the  bowel  well  above  the  internal  sphincter,  and  out 
on  the  buttock  a  considerable  distance  from  the  anus.  This  in 
its  turn  was  divided  with  the  knife,  but  the  result  of  the  division 
of  so  much  of  the  bowel  and  of  both  sphincters  was  a  consider- 
able degree  of  faecal  incontinence,  with  all  of  its  necessary  at- 
tendant evils.     Treatment  of  the  incontinence  by  the  passage  of 


106  DISEASES    OF    THE    EECTUM    AND    ANUS. 

bougies,  the  use  of  cold,  etc.,  resulted,  after  a  year's  continu- 
ance, in  great  benefit,  so  that  the  patient  seldom  soiled  his 
clothing  with  faeces,  except  when  the  bowels  were  unusually 
loose  ;  but  there  was  an  occasional  passage  of  a  slight  amount 
of  faeces,  a  frequent  escape  of  rectal  mucus,  and  a  constant 
annoying  sense  of  insecurity  in  the  patient's  mind  which  made 
him  anxious  for  any  further  relief  which  surgery  could  afford. 
The  actual  cause  of  the  open  condition  of  the  anus  lay  not  so 
much  in  any  weakening  of  the  power  of  the  sphincter,  which 
always  contracted  firmly  around  the  finger  in  the  rectum,  as  in 
the  peculiar  shape  of  the  anal  orifice,  resulting  from  the  con- 
traction of  the  cicatrix  formed  by  the  operation  for  fistula. 
This  was  situated  on  the  left  side,  was 
firm,  deep,  and  hard,  and,  by  its  contrac- 
tion, had  resulted  in  a  decided  drawing 
of  that  side  of  the  anal  orifice  over  still 
more  to  the  left,  so  that  no  amount  of 
sphincteric  contraction  could  close  it.  The 
condition  may  be  seen  by  a  glance  at  the 
diagram,  in  which  C  represents  the  cica- 
trix. 
fig.  36.-Operation  for  Re-        To  remedy  tllis  deformity,  I  made  with 

lief  of  Incontinence  of  Faeces.  _ 

a  Paquelm  cautery  the  burns  represented 
by  the  lines  1,  2,  3,  4,  and  5,  and  also  removed  two  longitudinal 
strips  of  mucous  membrane  from  the  inside  of  the  bowel,  clamp- 
ing the  tissue  deeply  with  Smith's  clamp,  and  using  the  cautery 
freely.  The  burns  represented  by  the  figures  were  also  deep, 
going  fairly  down  to  the  sphincter,  and  extending  from  well 
within  the  anus  to  the  distance  of  an  inch  upon  the  skin,  grow- 
ing deeper  as  they  reached  the  lower  end. 

The  operation  was  followed  by  more  pain  and  local  distur- 
bance than  I  anticipated,  and  there  was  at  one  time  a  brawny 
hardness  in  the  cellular  tissue  of  the  right  buttock  which  made 
me  uneasy  lest  the  patient  should  have  another  deep  abscess 
worse  than  the  first ;  but  all  this  passed  away,  and,  after  three 
weeks'  rest  in  bed,  he  was  again  able  to  attend  to  his  work.  At 
the  time  of  writing,  one  year  has  elapsed  since  the  operation. 
The  sphincter  contracts  firmly  upon  the  finger,  the  anus  is 
closed,  and  the  discharge  has  ceased.  In  other  words,  the 
patient  is  cured  by  the  production  of  a  stricture  at  the  anus 
sufficiently  tight  to  close  the  orifice,  and  I  have  no  longer  any 


ABSCESS   AND    FISTULA. 


107 


fear  that  I  might  have  done  too  much  in  the  operation  and 
made  his  last  state  worse  than  the  first  by  producing  a  stricture 
which  would  need  constant  future  care.  The  burns  seem  to 
have  been  just  sufficient  to  produce  the  desired  effect,  and  this, 
it  is  evident,  is  the  delicate  point  in  the  operation,  and  the  one 
for  which  no  rule  can  be  laid  down,  but  which  must  be  judged 
of  by  each  operator  in  each  particular  case. 

Incontinence  depends  more  upon  division  of  the  internal 
than  of  the  external  sphincter,  and  is  more  apt  to  follow  a 
double  division  of  the  fibres  than  a  single  one.  For  this  reason 
the  surgeon  should  always  endeavor  to  leave  a  few  fibres  at 
least  of  the  internal  muscle  in  any  operation,  and  the  incision 
should  always  be  directly  and  not  obliquely  across  the  fibres  of 
the  muscle.  It  is  also  well  to  remember  that  incontinence  is 
always  more  apt  to  result  from  division  of  the  muscles  in  the 
female  than  in  the  male. 

Fistula. — A  fistula  which  is  not  due  to  a  perforation  of  the 
rectal  wall  from  within  is  the  result  of  a  previous  abscess,  and, 
therefore,  in  enumerating  the  causes  of  abscess  those  of  fistulse 
have  also  been  given.  Like  the  abscesses  from' which  they  arise, 
they  may  well  be  divided  into  superficial  and  deep ;  or  into 
those  of  the  anus,  which  are  subcutaneous,  and  involve  at  the 
most  only  a  few  fibres  of  the  external 
sphincter,  and  those  of  the  rectum  and 
pelvis,  which  open  into  the  bowel  at  a 
higher  point.  Both  the  superficial  and 
deep  may  also  be  divided  into  the  com- 
plete, or  those  which  open  both  on  the 
skin  and  into  the  bowel  ;  the  external, 
which  open  only  on  the  skin,  and  the  in- 
terna], which  have  an  opening  only  within 
the  bowel  (Fig.  37). 

Superficial  Fistulm. — On  account  of 
the  special  laxity  of  the  submucous  con- 
nective tissue  in  this  region,  already  no- 
ticed, abscesses  show  little  tendency  to 
spontaneous  closure,  and  fistula  is  the 
common  result  when  left  to  their  own  course.  In  the  subcuta- 
neous fistula,  the  external  orifice  may  be  at  some  distance 
from  the  anus,  or  in  the  radiating  folds.  It  may  be  so  small  as 
to  escape  the  eye  in  a  cursory  examination,  unless  a  drop  of  pus 


Fig.  37.— Varieties  of  Fistula 
(Gosselin).  A,  anus  ;  R,  rectum  ; 
B,  complete  fistula  ;  C,  blind  in- 
ternal fistula;  D,  blind  external 
fistula. 


108  DISEASES    OF   THE    RECTUM    AND    ANUS. 

chance  to  be  squeezed  out  of  it  by  the  pressure  of  the  fingers  in 
pulling  open  the  parts  ;  and  when  discovered,  it  may  not  admit 
the  end  of  an  ordinary  probe.  The  surgeon  should,  therefore, 
always  be  provided  with  a  probe  of  small  size  and  of  pure  silver, 
which  admits  of  being  readily  bent,  for  using  in  these  examina- 
tions. 

The  presence  of  more  than  one  external  orifice  is  rare  in  sub- 
cutaneous fistula?  ;  and  an  internal  opening  will  be  found  in  the 
great  majority  of  cases,  if  properly  searched  for.  The  only  way 
to  settle  the  question  of  the  presence  or  absence  of  an  internal 
opening  in  any  doubtful  case  is  by  injecting  milk  through  the 
external  orifice.  In  the  vast  majority  of  cases  the  milk  will  be 
found  in  the  rectum,  and  the  internal  orifice  will  be  found  just 
within  the  external  sphincter.  It  may  sometimes  be  felt  in  this 
location  by  the  educated  finger  as  a  small  tubercle,  and  in  other 
cases  it  is  marked  by  a  distinct  loss  of  substance.  In  some  the 
internal  opening  will  be  found  in  the  radiating  folds  entirely 
below  the  fibres  of  the  sphincter,  and  in  others  it  may  be  much 
higher  up  the  bowel.1 

The  internal  orifice  does  not  in  all  cases  mark  the  superior 
limit  of  the  fistulous  track.  This  may  run  several  inches  up  the 
bowel  under  the  mucous  membrane,  when  the  internal  orifice  is 
just  within  the  external  sphincter  (Figs.  38,  39). 

The  track  of  a  fistula  is  sometimes  straight,  extending  di- 
rectly from  one  orifice  to  the  other ;  in  other  cases  a  track,  prop- 
erly speaking,  does  not  exist,  and  both  orifices  open  directly  into 
the  original  abscess  cavity.  If  the  external  orifice  be  very  small, 
the  cavity  may  at  any  time  become  distended  with  pus  and  give 
rise  to  all  the  symptoms  of  a  fresh  abscess,  till  the  pus  finds  an 
exit  either  through  the  old  opening  or  a  new  one.  The  external 
orifice  of  a  true,  straight  fistulous  track  is  generally  large,  and 
sometimes  free  enough  to  allow  of  the  escape  of  gas.  The  track  is 
lined  with  lardaceous  tissue  the  result  of  chronic  inflammation, 
and  in  this  may  be  found  numerous  blood-vessels  of  new  forma- 
tion. This  tissue,  by  preventing  all  contact  of  the  walls,  neces- 
sarily prevents  healing.  On  the  other  hand,  the  track  is  some- 
times lined  with  healthy  granulations  which  are  capable  of 
being  formed  into  new  tissue,  and  for  this  reason  a  fistula  will 
sometimes  heal  spontaneously. 

1  Ilibcs :  Rechcrches  sur  la  situation  de  1' orifice   interne  de  la  fistule  de  1'anus. 
Rev.  MOd.,  t.  i.,  1820. 


ABSCESS    AND    FISTULA. 


109 


The  history  will  sometimes  afford  valuable  information  as  to 
the  general  character  of  the  case.  The  history  of  a  slight 
abscess  and  the  escape  of  a  small  amount  of  pus  generally 
means  an  insignificant  fistula  with  external  and  internal  open- 
ings near  the  margin  of  the  anus  ;  while,  on  the  other  hand,  the 


Fig.  38.  Fig-  39. 

Fistulse  with  Double  Tracks.  (Molliere.) 
Fig.  38.  — AB,  deep  submuscular  track  resulting  from  an  ischio-rectal  abscess.     AI,  submu- 
cous track  running  up  and  down  the  bowel. 

Fig.  39. — DE,  Subtegumentary  and  submucous  fistula  with  internal  and  external  opening. 
DF,    deep  submuscular  track,  having  same  internal,  but  separate  external  opening. 

history  of  a  prolonged  inflammation  and  a  free  discharge  of 
pus  means  a  large  abscess  cavity  mounting  to  a  considerable 
height,  and  with  its  internal  orifice  at  a  correspondingly  high 
point. 

The  symptoms  caused  by  this  class  of  fistula?  vary  greatly. 
At  first  they  are  those  of  the  abscess  in  which  they  originate. 
After  that  the  one  great  symptom  is  the  incessant  discharge, 
sometimes  slight,  at  others  abundant ;  sometimes  purulent,  at 
others  serous  ;  always  fetid ;  sometimes  containing  faeces  and 
gas.  It  is  generally  the  stoppage  of  the  discharge  and  the  con- 
sequent filling  of  the  track  or  abscess  cavity  which  induces  the 
patient  to  seek  the  surgeon.  Besides  the  discharge  there  may 
be  no  symptoms  at  all,  or  there  may  be  more  or  less  uneasiness 
in  the  part,  and  pain  on  defecation,  with  the  constipation  which 
arises  from  the  fear  of  a  passage,  and  the  symptoms  to  which  it 
gives  rise.     Such  a  state  of  affairs  may  exist  for  many  years 


110  DISEASES    OF   THE   RECTUM    AND    ANUS. 

-without  aggravation,  or  without  causing  the  patient  to  seek 
relief. 

Deep  Fistula. — Deep  or  submuscular  fistulse  differ  greatly 
in  their  extent  and  gravity  from  those  last  described.  In  them 
the  track  is  large,  and  often  double  or  branching,  and  the  ex- 
ternal opening  may  be  far  away  from  the  amis.  The  whole 
perineum  and  gluteal  region  will  sometimes  be  found  to  be  per- 
forated by  openings.  In  a  case  sent  to  me  by  Dr.  R.  W.  Taylor, 
of  New  York,  I  counted  between  twenty  and  thirty  of  these 
discharging  points,  and  the  whole  perineum  and  surrounding 
region  were  hard,  brawny,  and  infiltrated.  The  man,  under  the 
pressure  of  his  sufferings  probably,  had  become  a  confirmed 
opium-eater  and  was  in  a  deplorable  plight. 

Pelvic  Fistula?. — The  fistula  resulting  from  an  abscess  of 
the  superior  pelvi-rectal  space  is  generally  of  the  blind  external 
variety.  The  track  is  deep  and  the  probe  passed  into  it  can 
hardly  be  felt  from  the  rectum.  The  external  opening  may  be 
far  away  from  the  anus,  and  there  may  be  several  tracks  and 
openings  which  may  branch  off  from  each  other,  or  all  com- 
municate with  a  common  abscess  cavity  above  the  levator-ani 
muscle. 

The  track  in  some  of  these  cases  has  been  known  to  take  a 
remarkably  irregular  course.  Sir  A.  Cooper '  mentions  an  au- 
topsy where  a  fistula  opened  in  the  groin,  followed  the  course 
of  the  spermatic  cord,  and  ended  in  what  seemed  like  an  ordi- 
nary fistula  in  ano ;  and  cases  in  which  the  pus  has  burrowed 
under  the  gluteal  muscles  and  finally  opened  in  the  thigh  or 
even  nearly  at  the  popliteal  space,  are  not  uncommon.  This 
form  of  disease  is  rather  more  common  in  males  than  in  females. 

Blind  Internal  Fistula. — Fistula  with  internal  openings 
alone  have  a  somewhat  special  pathology.  When  caused  by  an 
abscess  it  is  generally  by  one  of  the  deep  variety  which  has 
opened  into  the  rectum  high  up  and  continues  to  discharge  in 
this  way.  The  abscess  causing  such  a  fistula  may,  however,  be 
a  small  submucous  one,  or  a  large  subcutaneous  one,  and  the 
symptoms  will  then  be  pain,  spontaneous  discharge  of  pus  from 
the  bowel,  and  subsequently  pain  after  defecation  resembling 
that  of  a  fissure.  There  is  another,  and  perhaps  more  common 
class  of  internal  fistula  in  which  the  oj>ening  is  not  the  result 


1  Lecture  on  Principle  and  Practice  of  Surgery,  with  notes  by  Tyrell,  t.  ii.,  p.  326. 


ABSCESS    AND    FISTULA.  Ill 

of  the  breaking  of  an  abscess,  but  in  which  the  opening  is  first 
formed  by  ulceration,  and  the  track  is  a  secondary  consequence. 
This  pathological  fact  was  proved  by  the  well-known  investi- 
gations of  Blbes,  who  believed  that  the  internal  orifice  was 
always  the  first  formed,  but  here  he  was  undoubtedly  in  error. 

A  circumscribed  ulcer  which  shall  perforate  the  mucous 
membrane  and  result  in  internal  fistula  may  be  due  to  several 
causes :  to  the  inflammation  of  one  of  the  lacunae  just  above  the 
sphincter  from  the  lodgement  within  it  of  a  particle  of  hard 
faeces ;  to  rupture  of  an  inflamed  internal  haemorrhoid  ;  to  the 
application  of  strong  acids  to  haemorrhoids  ;  to  operations  upon 
the  rectum,  generally  for  haemorrhoids  ;  and  to  the  peculiar 
ulceration  met  with  in  tubercular  patients,  but  not  necessarily 
tubercular  in  its  nature. 

Such  a  condition  is  a  very  painful  one.  The  opening,  which 
may  be  large  enough  to  show  a  distinct  loss  of  substance  to  the 
touch,  catches  and  retains  particles  of  faeces,  causing  a  burning 
pain  which  may  last  many  hours  after  defecation.  As  a  result 
of  the  opening  an  abscess  forms  after  a  time,  with  the  usual 
symptoms,  the  induration  of  which  may  be  felt  externally. 
When  the  abscess  is  small  and  the  induration  not  extensive  a 
speculum  examination  may  reveal  the  ulcer  ;  but  the  fistulous 
tract  and  abscess  may  escape— a  mistake  which  will  render  all 
treatment  directed  toward  the  cure  of  the  ulcer  of  no  avail. 
There  may  indeed  be  several  ulcers,  only  one  of  which  has  a 
fistula  connected  with  it. 

Treatment. — A  fistula  may  heal  spontaneously  or  after  a 
very  slight  excitement  to  reparative  action,  such  as  the  mere 
passage  of  a  probe  in  making  an  examination.  It  has  been 
mentioned  that  the  track  is  sometimes  lined  with  healthy  granu- 
lations, and  that  these  may  result  in  new  tissue  which  shall 
close  it.  I  have  the  notes  of  one  such  case  where  a  fistula  of 
several  years'  standing  closed  spontaneously  without  even  the 
passage  of  a  probe  to  excite  it  to  reparative  action. 

Setting  aside  these  cases,  we  are  at  once  brought  to  the 
question  which  will  often  be  asked  by  the  patient,  and  which 
the  surgeon  may  not  always  be  able  to  answer  to  his  own  satis- 
faction, whether  or  not  it  is  always  best,  or  even  safe,  to  try 
to  cure  a  fistula.  In  certain  cases  of  Bright' s  disease,  cancer, 
cardiac  and  hepatic  affections,  etc.,  all  surgical  interference 
may  be  plainly  contra-indicated  ;  but  the  question  is  most  apt 


112  DISEASES    OF    THE    EECTUM    AND    ANUS. 

to  arise  in  connection  with  pulmonary  affections.  There  can  be 
little  doubt  that  phthisical  patients  are  especially  predisposed 
to  this  affection,  and  the  reason  is  probably  in  great  measure  a 
mechanical  one,  depending  npon  a  loss  of  fat  in  the  ischio-rectal 
fosse  and  a  resulting  loss  of  support  to  the  hemorrhoidal  veins. 
From  this  there  results  a  venous  congestion  and  final  dilatation 
or  rupture  of  the  vessels,  which,  with  the  cough  and  concus- 
sion, leads  eventually  to  abscess. 

I  believe  it  to  be  a  safe  rule  to  operate  on  phthisical  patients 
as  upon  others,  being  led  by  the  idea  that  one  exhausting  dis- 
ease— phthisis — is  better  than  two — phthisis  and  fistula.  I  have 
many  times  followed  this  rule  with  happy  results  as  to  im- 
proved general  health  after  the  cure  of  the  fistula.  Once  only 
has  it  happened  to  me  to  see  the  cure  of  a  fistula  followed  by  a 
marked  increase  of  the  lung  trouble,  and  even  in  such  a  case 
the  relation  between  cause  and  effect  cannot  be  established. 
There  are  several  rules  which  should  be  carefully  regarded  in 
this  class  of  cases,  however.  No  cautious  practitioner  would 
think  of  operating  either  in  a  very  advanced  or  a  rapidly  ad- 
vancing lung  trouble.  Cough,  when  violent  and  frequent,  is 
also  a  decided  contra-indication,  interfering,  as  it  does  very  cer- 
tainly, with  the  healing  of  the  wound.  The  following  case  will 
perhaps  illustrate  the  line  of  treatment  to  be  followed  in  a  gen- 
eral way. 

Case.  Cure  of  Fistula  in  a  Phthisical  Patient. — A  theo- 
logical student,  aged  twenty-eight,  applied  to  me  from  a  neigh- 
boring city  for  relief  from  a  large  subcutaneous  abscess,  with  an 
internal  opening  within  the  sphincter,  and  an  external  one  at 
some  distance  from  the  anus.  The  probe  could  easily  be  passed 
a  considerable  distance  in  every  direction  beneath  the  under- 
mined skin.  The  discharge  was  very  profuse.  This  condition 
had  existed  for  several  months ;  the  patient  was  much  re- 
duced in  weight ;  there  was  consolidation  in  the  apex  of  one 
lung,  with  a  history  of  phthisis  and  hemorrhages. 

The  internal  and  external  orifices  were  connected  by  an  in- 
cision involving  the  external  sphincter,  and  the  abscess  cavity 
was  laid  open  for  a  distance  of  four  inches  along  the  perineum, 
and  dressed  with  picked  lint.  After  a  fortnight's  rest  in  his 
room,  the  patient  being  partially  dressed  most  of  the  time,  and 
spending  his  days  on  the  lounge  or  easy-chair  rather  than  in 
bed,  reparative  action  seemed  to  come  to  a  standstill,  and  with 


ABSCESS    AND    FISTULA.  113 

careful  directions  as  to  dressing  the  wound,  I  sent  him  off  into 
the  mountains.  He  reported  at  my  office  after  an  interval  of 
three  months  spent  in  the  woods,  during  which  time  he  had  fre- 
quently been  on  horseback  several  hours  at  a  time.  The  change 
in  his  general  condition  was  very  remarkable,  he  having  gained 
nearly  twenty  pounds  in  weight.  The  abscess  cavity  was  nearly, 
but  not  quite  closed,  and  again  he  returned  to  the  country,  with 
the  understanding  that  he  should  report  in  the  city  every  fort- 
night. In  just  six  months  from  the  operation  the  wound  was 
entirely  healed,  there  had  been  no  exacerbation  in  the  lung 
troubles,  and  the  patient  was  in  better  general  condition  than 
for  years  previous. 

In  the  former  edition  of  this  work  I  made  the  statement  that 
I  had  yet  to  meet  the  first  case  of  this  kind  which,  under  suit- 
able and  careful  general  and  local  treatment,  refused  to  heal 
after  the  operation.  It  is  well,  however,  to  give  a  guarded  prog- 
nosis, and  within  the  past  year  I  have  had  one  case  in  which, 
though  the  patient  was  greatly  benefited  by  the  operation,  both 
as  to  the  local  trouble  and  his  general  condition,  the  wound  has 
failed  to  cicatrize.    The  notes  of  it  are  as  follows : 

Case.    Blind  Internal  Fistula  in  a  Phthisical  Patient. — 

Mr.  D ,  aged  thirty-eight.     The  patient  has  had  phthisis  for 

three  years,  which  has  advanced  to  the  formation  of  cavities  in 
both  lungs,  and  is  accompanied  by  the  usual  general  symptoms 
of  that  condition.  About  three  weeks  before  consulting  me  he 
had  the  usual  signs  of  an  abscess  on  the  left  side  of  the  anus, 
which  resulted  in  a  very  profuse  purulent  discharge.  Upon  ex- 
amination I  discovered,  just  within  the  margin  of  the  anus,  but 
hardly  above  the  sphincter,  a  loss  of  tissue  on  the  left  side  of 
the  bowel  into  which  the  end  of  the  finger  readily  passed.  The 
corresponding  buttock  was  infiltrated,  and  pressure  over  it 
caused  a  free  discharge  of  pus  from  the  anus,  showing  a  con- 
siderable abscess  cavity.  This  was  freely  incised  under  ether 
by  entering  a  curved  bistoury  at  the  internal  opening  and  cut- 
ting outward  over  the  buttock.  The  cavity  was  scraped  out 
with  the  finger,  and  dressed  with  lint  and  carbolized  oil,  and  the 
patient  was  put  to  bed  for  three  days.  At  the  end  of  that  time 
the  wound  was  doing  well  but  the  patient  was  not,  and  I  was 
obliged  to  let  him  sit  up  and  take  moderate  exercise  in  the  open 
air. 

The  operation  was  performed  January  7th.  Twenty  days 
8 


114  DISEASES    OF    THE    RECTUM    AND    ANUS. 

later  I  made  a  note  that  the  wound  was  closing  nicely,  and  the 
patient  in  a  fair  way  to  recover.  But,  February  19th,  I  dis- 
covered that  there  had  been  some  burrowing  of  pus,  and  it  was 
necessary  to  slit  up  a  small  sinus  which  had  formed.  The 
wound  looked  healthy,  but  the  patient's  general  condition  was 
very  bad  indeed,  and  he  objected  most  strenuously  to  being  con- 
lined  to  his  bed  or  even  to  his  room.  The  following  four  months 
were  passed  in  a  long,  patient  struggle  on  my  part  and  that  of 
the  patient  to  induce  a  complete  closure  of  the  wound.  Every 
form  of  treatment  which  ingenuity  could  suggest  was  tried,  and 
it  would  be  useless  to  enumerate  them.  More  than  once  we 
congratulated  ourselves  that  the  work  was  done,  and  that  an- 
other week  would  end  the  case,  when  a  fresh  pocket  would 
form,  at  first  very  slight  but  rapidly  increasing,  and  the  task 
had  to  be  undertaken  again.  During  all  this  time  the  patient 
was  up  and  about,  and  improving  in  his  general  condition,  so 
that  in  the  early  summer,  when  I  last  saw  him,  he  had  gained 
decidedly  in  flesh  and  the  local  trouble  caused  him  so  little  dis- 
comfort that  he  had  ceased  to  wear  a  bandage.  But  there  were 
still  two  small  pockets  which  needed  to  be  laid  open.  He  is 
now  in  a  condition  which  would  warrant  the  enforcement  of  the 
most  important  element  of  the  treatment,  and  the  only  one 
which  has  never  been  practised — absolute  rest  in  bed  after 
opening  the  sinuses — and  by  this  means  I  still  hope  to  get  a 
positive  cure  after  his  summer  rustication  has  done  all  that  can 
be  done  in  that  way. 

From  the  peculiar  origin  of  this  case,  and  once  or  twice  from 
the  peculiar  appearance  of  the  nearly  cicatrized  wound  when  it 
was  reduced  to  a  surface  the  size  of  the  little  finger-nail,  I  have 
been  inclined  to  suspect  that  the  starting-point  of  the  disease 
might  have  been  a  deposit  of  true  tubercle.  This  would  fully 
account  for  the  lack  of  success  of  the  treatment,  but  I  have 
never  been  able  to  convince  myself  of  the  fact. 

In  cases  of  fistula  in  phthisical  patients,  the  sphincters 
should  be  interfered  with  as  little  as  possible,  as  they  are  apt 
to  be  weak  at  the  best.  The  internal  orifice  is  apt  to  be  large 
and  ragged,  and  the  external  may  be  the  same.  The  tendency 
to  undermine  the  skin  is  always  marked,  and  the  discharge  is 
generally  thin  and  watery. 

Cauterization. — It  is  not  necessary  even  to  enumerate  the 
various  substances  which  from  time  out  of  date  have  been  ad- 


ABSCESS    AND    FISTULA.  115 

vocated  for  this  purpose.  Among  those  for  which  good  results 
have  been  claimed,  iodine  holds  the  first  rank.1  There  is  no 
doubt  that  by  its  use  certain  fistulae  and  abscesses  may  be  made 
to  heal,  but  the  plan  is  uncertain  and  not  very  reliable. 

The  operation  consists  in  closing  the  internal  opening  with  a 
finger  in  the  rectum,  and  then  injecting  the  fluid  with  a  small 
syringe  through  the  external  orifice,  using  pressure  enough  on 
the  track  to  bring  the  fluid  into  contact  with  every  part.  In 
the  place  of  iodine,  nitrate  of  silver  either  in  solution  or  fused 
upon  a  probe,  the  tincture  of  iron,  or  carbolic  acid,  may  be 
used.  The  galvano-cautery  wire,  or  a  simple  hot  iron,  may  also 
be  employed  to  modify  the  track  ;  and  a  fine  sea- tangle  tent 
carefully  introduced  will  sometimes  set  up  reparative  action. 
By  any  of  these  means  failure  will  be  the  rule,  but  success  may 
occasionally  be  secured  after  faithful  trial. 

The  Ligature. — Under  the  head  of  the  ligature  may  be  in- 
cluded also  its  different  modifications — ecrasement  lineaire, 
elastic  ligature,  and  the  galvano-cautery  wire. 

The  method  of  cure  by  the  simple  ligature  consists  in  pass- 
ing a  strong  cord  through  the  fistula  from  the  external  opening, 
through  the  internal,  and  out  at  the  anus,  then  in  tying  the  two 
ends,  and  tightening  the  loop  from  day  to  day  till  the  tissue 
included  is  divided.  The  operation  is  generally  effectual,  but 
it  is  also  painful,  tedious,  and  uncertain.  It  is  a  substitute  for 
the  knife,  a  concession  to  the  fear  of  being  cut,  and  it  is  free 
from  haemorrhage  ;  but  it  only  accomplishes  in  the  end,  and 
sometimes  after  weeks  of  suffering,  what  the  knife  accomplishes 
in  a  moment ;  and  except  for  the  single  fact  that  by  its  use 
haemorrhage  may  be  avoided,  it  would  bear  no  comparison  with 
the  latter. 

If  this  mode  of  treatment  is  for  any  reason  decided  upon, 
there  are  certain  modifications  of  the  operation  which  are  much 
to  be  preferred  to  the  simple  cord.  The  method  of  immediately 
cutting  through  the  tissues  by  attaching  the  ends  of  the  cord  to 
the  handle  of  an  ecraseur  {ecrasement  lineaire)  is  a  much  better 
way  of  attaining  the  same  end,  which  is  due  to  Chassaignac. 
There  are,  however,  two  methods  of  dividing  the  tissues  which 
are  still  better  than  this — one  by  the  galvano-cautery  wire,  the 
other  by  the  elastic  ligature.     The  galvano-cautery  wire  has  the 

1  Boinet  :    Traitc  d'iodotherapie. 


116  DISEASES    OF    THE    RECTUM    AND    ANUS. 

same  advantage  over  the  knife  as  the  Ligature  in  preventing 
haemorrhage  ;  and  it  is  not  particularly  painful  in  its  applica- 
tion. In  using  it,  as  little  heat  should  be  used  as  is  possible  to 
slowly  divide  the  tissue,  or  haemorrhage  may  occur  and  all  its 
advantages  be  lost.  On  account  of  the  expense  of  the  appara- 
tus, and  the  skill  required  for  its  management,  this  method  has 
never  become  very  popular  with  the  general  practitioner,  but  it 
is  very  successful  in  the  hands  of  a  few. 

Probably  the  best  of  all  methods  next  to  the  knife  is  that 
of  the  elastic  ligature.  The  cord  in  this  case  is  of  solid  rubber, 
which  is  drawn  as  tightly  as  possible — the  tighter  the  better — 
and  then  held  on  the  stretch  by  slipping  a  soft  metal  ring  over 
the  ends  and  squeezing  its  two  sides  together  close  up  against 
the  tissues.  In  the  course  of  a  few  days  the  ligature  will  be 
found  to  have  cut  its  way  through  the  included  tissues,  the 
time  depending  on  the  quantity  and  quality  of  the  mass  to  be 
cut. 

Various  devices  have  been  recommended  for  facilitating  the 
passage  of  the  ligature.  The  best  known  is  Allingham's,  Fig. 
40.  In  using  it,  remember  that  it  is  intended  to  draw  the  cord 
from  the  rectum  out  of  the  external  orifice,  and  not  vice  versa. 
Helmuth,  of  New  York,  has  modified  the  instrument,  and  I 
think  with  advantage,  Fig.  41,  but  the  least  elaborate  and  most 
effective  instrument  for  the  purpose  in  my  own  hands  is  a  sim- 
ple silver-eyed  probe  which  is  threaded  with  the  elastic  cord 
and  then  passed  from  the  external  orifice  through  the  track  and 
out  at  the  anus.  I  once  had  an  awkward  accident  with  Ailing- 
ham's  instrument,  which  broke  in  my  hand  in  a  moderately 
deep  and  hard  track. 

After  the  ligature  is  in  place,  the  patient  is  allowed  to  go 
about  his  ordinary  pursuits,  and  this  is  claimed  as  one  great 
advantage  of  this  method.  I  have  never  been  able  to  under- 
stand why  cutting  with  a  string  should  permit  of  any  more 
liberty  than  cutting  with  a  knife.  The  patient,  it  is  true,  will 
generally  get  well  if  he  goes  about  while  the  string  is  doing  its 
work,  and  so  he  will  after  the  operation  with  the  knife  ;  but  in 
both  cases  the  healing  will  be  facilitated  by  rest.  The  operation 
is  said  to  be  painless.  I  have  not  found  it  so.  Both  the  pass- 
ing of  the  cord,  and  its  tension  for  the  first  forty-eight  hours, 
have  been  bitterly  complained  of  in  some  of  my  own  cases.  The 
healing  has  already  begun  before  the  ligature  comes  away  ;  but 


ABSCE9S    AND    FISTULA. 


117 


with  the  dropping  out  of  the  cord  there  will  sometimes  be  found 
a  considerable  slough  in  the  line  of  strangulation  which  may 
require  some  days  for  its  separation. 

The  elastic  ligature  has  undoubted  advantages  over  the  knife 
in   cases  where   the  latter  is  contra-indicated  by  the  fear  of 


«sH 


II 


PlG.  40. — Allingham's  Ligature  Carrier. 


Fig.  41. — Helmuth's  Ligature  Carrier. 


haemorrhage,  as  in  a  fistula  running  high  up  the  bowel  where 
haemorrhage  may  be  a  serious  matter,  or  where  the  patient  re- 
fuses to  submit  to  a  cutting  operation.  Of  all  the  methods  of 
cutting  with  a  string  it  is  the  best  ;  but,  after  all,  it  is  only  a 
substitute  for  the  knife,  and  for  my  own  part  I  must  plead 


118  DISEASES    OF    THE    RECTUM    AND    ANUS. 

guilty  to  a  preference  for  cutting  with  a  knife  when  cutting  is 
necessary. 

Incision. — The  operation  for  fistula  by  incision  may  be 
greatly  facilitated  by  the  observance  of  several  minor  details. 
In  this  as  in  other  operations  on  the  part,  the  bowels  should  be 
thoroughly  emptied  on  the  previous  day.  Care  must  be  ex- 
ercised, lest  in  the  endeavor  to  free  the  alimentary  canal  a 
diarrhoea  be  excited,  for  this  will  prove  anything  but  an  agree- 
able complication  for  the  operator.  In  all  cases  in  which  the 
track  is  of  any  considerable  depth,  or  in  which,  on  account  of 
sensitiveness  of  the  patient,  the  surgeon  has  not  been  able  to 
assure  himself  of  the  exact  extent  of  the  disease  and  the  absence 
of  any  side  tracks  or  diverticula,  ether  should  be  given  and  the 
anus  gently  and  completely  dilated  before  the  operation.  It  is 
only  in  the  simplest  cases  that  the  incision  may  be  made  with- 
out ether,  and  then  the  best  chance  of  a  thoroughly  satisfactory 
exploration  is  missed,  and  the  way  is  opened  for  an  incomplete 
and  therefore  unsuccessful  operation. 

With  regard  to  position  the  operator  may  choose  between 
placing  the  patient  on  the  affected  side  or  on  the  back.  In 
women  the  former  is  generally  preferable.  A  director  with 
probe  point  should  be  passed  through  the  external  orifice  into 
the  bowel  and  brought  out  at  the  anus  by  the  index  finger  of 
the  other  hand,  which  should  in  any  case  be  passed  into  the 
bowel  before  the  probe  is  inserted  into  the  external  opening. 
The  track  should  now  be  carefully  and  thoroughly  explored 
and  its  extent  discovered.  This  should  be  done  deliberately 
and  without  haste,  and  hence  the  advantage  of  an  anaesthetic. 
When  the  patient  is  not  etherized  there  is  always  a  tempta- 
tion, when  the  end  of  the  probe  is  felt  against  the  finger  in  the 
rectum,  to  bring  it  out  at  the  anus,  follow  it  instantly  with  the 
bistoury,  and  quiet  the  sufferer  with  the  cheering  assurance  that 
all  is  finished  ;  but  a  seemingly  insignificant  case  may  have  a 
deep  track  connected  with  it  which  must  be  divided  before  a 
cure  can  be  effect  id. 

Having  by  careful  examination  decided  just  how  much 
«ut  ting  is  to  be  done,  the  choice  of  the  instrument  rests  with 
each  operator.  In  simple  cases,  where  the  track  is  superficial, 
I  frequently  use  a  knife  of  my  own  invention  which  (like  most 
new  inventions)  I  found  after  having  it  manufactured,  exactly 
resembled  those  in  use  in  the  fourteenth  and  fifteenth  century, 


ABSCESS    AND    FISTULA.  119 

though  somewhat  smaller  and  less  formidable  in  appearance." 
It  is  represented  in  Fig.  42,  and  consists  of  a  flexible  probe  at 
the  end  of  a  curved  bistoury.  The  probe  point  should  blend 
as  gradually  as  possible  with  the  cutting  edge,  as  anything  like 
a  shoulder  at  the  junction  of  the  two  interferes  greatly  with  its 
use.  I  have  thought  that  in  suitable  cases  the  operation  was 
rendered  more  speedy  and  less  painful  by  the  use  of  this  com- 
bined instrument ;  but  it  is  not  well  adapted  to  those  cases  in 


Pig.  42.— Author's  Fistula  Knife. 

which  the  track  runs  any  distance  up  the  bowel ;  and  where  the 
patient  is  etherized  it  has  no  advantages  over  the  director  on 
which  the  bistoury  is  generally  passed.  It  is  especially  adapted 
for  operating  without  ether. 

In  subcutaneous  fistulse  the  track  should  be  divided  from 
the  external  to  the  internal  orifice.  If  there  be  at  the  same 
time  any  undermining  of  the  skin  with  tracks  leading  off  in 
different  directions,  these  also  should  be  laid  open,  so  that  all 
may  be  converted  into  an  open  wound.     For  deep  fistulsB  the 


Fig.  43.— Gorget. 

knife  or  scissors  should  be  strongly  made,  for  it  is  not  a  very 
difficult  matter  to  break  an  ordinary  scalpel  in  a  deep  fistula.  A 
heavy  steel  director  may  also  be  snapped  in  an  attempt  to  bring 
the  end  out  of  the  anus  preparatory  to  making  the  incision  ;  and 
should  the  internal  orifice  be  high  up,  and  the  external  at  some 
distance  from  the  anus,  so  that  the  amount  of  tissue  to  be 

1  I  am  indebted  to  my  friend,  Dr.  James  L.  Little,  for  calling  my  attention  to  the 
plates  in  Heister's  Surgery,  showing  this  instrument — the  old-fashioned  syringotome. 


120 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


divided  is  large,  it  is  often  better  to  use  the  wooden  gorget 
to  guard  the  opposite  side  of  the  rectum  and  dispense  with  the 
director  after  the  knife  has  been  passed.  (Fig.  43.)  The  end  of 
the  knife  may  be  firmly  fixed  into  the  wood  and  both  with- 
drawn simultaneously,  Fig.  44,  or  the  incision  may  be  made  by 


Fig.  44. — Operation  for  Fistula  with  Gorget.    (Bernard  and  Huette.) 

cutting  on  the  gorget.  Allingham  prefers  a  pair  of  spring 
scissors,  one  blade  of  which  runs  in  a  director  the  groove  of 
which  is  more  than  a  semicircle,  for  cutting  deep  tracks.  (Fig. 
45.) 

Some  difference  of  opinion  exists  among  different  writers  as 
to  the  proper  method  of  treating  the  track  that  will  often  be 


*e^ 


Fig.  45. — Allingham's  Spring-Scissors  for  Fistula. 

found  running  along  the  bowel  above  the  internal  orifice,  and 
directly  contrary  opinions  are  taught  as  to  the  necessity  for  its 
complete  division.  The  operation  is  of  course  rendered  more 
severe  by  the  division  of  such  a  sinus  in  addition  to  the  fistula, 
and  the  danger  of  haemorrhage  is  increased ;  but  one  can  never 


ABSCESS    AND    FISTULA.  121 

be  sure  that  the  operation  will  be  successful  when  such  a  track 
is  left,  though  no  doubt  many  cases  have  turned  out  well. 
With  regard  to  haemorrhage  in  such  cases,  it  will  be  found  that 
the  sinus  has  generally  burrowed  under  the  mucous  membrane, 
and  that  the  vessels  have  remained  in  the  deeper  layers  of  the 
bowel,  so  that  the  division  of  the  sinus  does  not  of  necessity  in- 
volve that  of  any  large  vessel,  though  it  extend  far  up  the  bowel. 

Many  of  these  sinuses  may  best  be  divided  with  the  scissors, 
and  the  haemorrhage,  if  it  be  profuse,  dealt  with  according  to 
the  rules  already  given.  If,  however,  haemorrhage  be  feared 
beforehand,  the  track  may  be  divided  with  the  ecraseur,  or  a 
small  canula  may  first  be  passed,  through  this  a  wire,  and  finally 
by  means  of  the  wire  an  elastic  ligature. 

When  no  internal  orifice  can  be  found,  but  the  mucous  mem- 
brane feels  undermined,  and  the  probe  can  be  felt  by  the  finger 
in  the  rectum,  separated  only  by  a  thin  layer  of  mucous  mem- 
brane, it  is  a  good  plan,  when  the  fistula  is  not  too  deep,  to  force 
an  internal  opening  and  treat  the  fistula  as  though  it  were  com- 
plete. When  there  are  two  internal  openings,  both  should  be 
included  in  one  incision.  When,  after  the  incision,  the  diseased 
integument  is  found  to  overlap  the  cut,  and  hang  into  it,  it 
should  be  cut  away,  and  in  old  tracks  the  healing  may  be  has- 
tened many  days  by  thoroughly  scraping  out  the  lardaceous 
wall  with  the  handle  of  the  scalpel,  or  even  scarifying  it  in  sev- 
eral places,  so  that  a  healthy  reparative  action  may  be  set  up. 

In  cases  of  horse-shoe  fistula  with  two  external  orifices  and 
one  internal  one,  it  is  generally  best  to  do  the  usual  operation 
on  one  side  only,  and  to  dilate  the  opening  on  the  opposite  side, 
so  as  to  allow  of  free  escape  of  pus. 

Where  the  fistulous  tracks  exist  in  great  numbers — twenty 
or  thirty  in  some  cases — two  or  three  operations  may  be  advisa- 
ble at  intervals,  rather  than  to  attempt  to  do  all  at  one  sitting, 
lest  the  patient's  reparative  powers  should  be  unequal  to  the 
task  thrown  upon  them.  In  such  cases  there  will  often  be 
found  two  or  three  tracks  which  may  be  considered  as  primary, 
into  which  the  others  run  ;  and  each  of  these,  with  its  branches, 
may  be  dealt  with  at  a  separate  operation.  Many  of  the  tracks 
will  be  found  to  run  away  from  the  bowel  under  the  skin  of  the 
buttock,  or  toward  the  scrotum,  and  these  may  be  induced  to 
heal  by  laying  them  open,  without  interfering  with  the  sphinc- 
ters.    It  will  sometimes  be  necessary  to  divide  the  sphincter 


122  DISEASES    OF    THE    KECTUM    AND    ANUS. 

several  times,  however,  before  the  cure  can  be  completed,  and  a 
certain  degree  of  incontinence  may  be  expected  as  a  result. 

In  such  cases  the  anal  region  is  generally  greatly  hardened 
and  infiltrated,  and  free  haemorrhage  may  be  expected.  The 
best  weapon  with  which  to  meet  it  is  the  cautery  of  Paquelin. 

In  the  matter  of  dressings  after  the  incision,  much  skill  may 
be  displayed.  Immediately  after  the  operation,  a  dressing  of 
dry  picked  lint,  or  if  there  be  an  abscess  cavity,  of  lint  soaked 
in  carbolized  oil,  is  as  good  as  any,  and  this  should  be  kept  in 
place  by  a  T  bandage.  To  save  the  patient  as  much  pain  and 
annoyance  as  possible,  this  should  not  be  removed  till  suppura- 
tion has  been  established.  Subsequent  dressings  may  be  of  the 
same  material,  and  should  be  changed  daily.  The  wound 
should  not  be  tightly  packed  with  lint.  It  will  heal  from  the 
bottom  if  its  surfaces  are  kept  apart  or  separated  daily  by  the 
ringer  of  the  surgeon.  Care  is  always  necessary  to  prevent  an 
immediate  union  of  the  cutaneous  edges  of  the  incision.  I  have 
seen  a  remarkably  well-pleased  patient  come  to  me  and  report 
himself  as  entirely  cured  a  week  after  I  had  divided  his  fistula, 
in  consultation  with  his  medical  attendant,  and  have  found  on 
examination  that  the  incision  had  healed  very  kindly  by  first 
intention  through  its  whole  extent,  and  that  the  fistulous  track 
was  exactly  as  it  was  before  the  cut. 

Healing  may  be  indefinitely  delayed  by  too  frequent  dress- 
ings or  by  stuffing  the  wound  tightly  with  lint,  with  the  inten- 
tion of  forcing  it  to  heal  from  the  bottom.  Under  such  treat- 
ment, healthy  granulations  may  entirely  disappear,  and  the  cut 
surface  assume  a  mucous-membrane-like  appearance,  and  so  re- 
main. Standing  or  walking  always  delays,  and  may  sometimes 
entirely  prevent  healing. 

During  the  treatment,  the  burrowing  of  pus  and  the  forma- 
tion of  a  new  pocket  should  always  be  carefully  watched  for, 
and  met  by  incision. 

The  1 1 hemorrhage  in  an  ordinary  operation  for  fistula  is  sel- 
dom profuse  enough  to  cause  the  surgeon  any  uneasiness,  and 
is  almost  alwa3's  easily  controlled  by  packing  the  incision  with 
lint,  and  making  firm  pressure  with  a  compress  held  in  place  by 
a  T  bandage.  A  free  arterial  haemorrhage  from  a  vessel  well 
up  the  rectum  may,  however,  be  alarming,  and  if  not  controlled 
by  the  admission  of  air  or  the  application  of  ice  to  the  part,  the 
rectum  must  be  tamponed. 


ABSCESS    AND    FISTULA.  123 

Fistulse  of  the  blind  internal  variety  can  only  be  dealt  with 
rationally  by  incision.  A  speculum  should  first  be  introduced 
and  a  silver  director  bent  into  the  form  of  a  hook  passed  into 
the  orifice  and  brought  down  to  the  bottom  of  the  track,  with 
this  as  a  guide  the  fistula  may  be  opened  into  the  bowel. 

The  incision  should  always  be  continued  through  the  sphinc- 
ter and  the  anus,  so  that  the  wound  may  be  properly  dressed 
and  drained,  otherwise  the  operation  will  merely  serve  to  con- 
vert a  small  internal  opening  into  a  larger  one.  An  operation 
of  this  kind  is  always  more  apt  to  be  followed  by  a  concealed 
haemorrhage  into  the  rectum  than  one  for  a  complete  fistula, 
and  this  should  be  guarded  against  by  a  careful  plugging  of 
the  wound  and  by  the  application  of  dry  persulphate  of  iron  if 
necessary. 

The  abscess  in  connection  with  a  blind  internal  fistula  may 
sometimes  be  detected  by  the  induration  which  may  be  felt 
through  the  skin  of  the  ischio-rectal  fossa.  In  such  a  case,  after 
the  director  has  been  passed  into  the  internal  orifice,  a  counter- 
opening  should  be  made  into  the  abscess  through  the  skin,  using 
the  director  for  a  guide  for  the  incision.  In  this  way  the  blind 
internal  variety  is  changed  into  the  complete,  and  the  usual 
operation  of  division  into  the  bowel  may  be  performed. 

After  what  has  been  said  of  the  origin  and  extent  of  ab- 
scesses of  the  superior  pelvi- rectal  space,  it  is  evident  that  there 
may  result  from  them  a  class  of  fistulse  which  are  not  to  be 
operated  upon  by  any  of  the  methods  we  have  described — fis- 
tulse so  deep  and  extensive  as  to  contra-indicate  all  operative 
interference.  And  yet  much  may  be  done,  even  in  the  worst 
cases  of  this  kind,  and  by  proper  treatment  some  may  be  cured. 
The  first  attempt  of  the  surgeon  should  always  be  toward  effect- 
ing a  cure  without  cutting  the  track  into  the  bowel.  External 
and  comparatively  free  incisions  may  be  made,  which  shall  not 
implicate  the  anus,  and  through  them  drainage  tubes  may  be 
passed  into  the  abscess  cavity  so  that  it  may  be  freely  emptied. 
Through  the  drainage  tube  stimulating  injections  maybe  made, 
and  the  abscess  treated  as  an  abscess  elsewhere  would  be,  by 
rest  and  attention  to  the  general  health.  A  cure  may  some- 
times be  effected  in  this  way  in  a  very  unpromising  case. 

When  all  these  measures  have  been  exhausted  and  it  be- 
comes necessary  to  open  the  sinus  into  the  bowel,  the  danger  of 
haemorrhage  may  be  overcome  by  the  elastic  ligature  or  the  en- 


124  DISEASES    OF    THE    RECTUM    AND    ANUS. 

terotome.  Of  these  the  former  is  preferable,  but  if  it  be  deemed 
advisable  to  use  the  latter,  the  form  shown  in  Fig.  46,  which 
has  been  invented  by  Richet  for  this  purpose,  is  the  most  con- 
venient. 

Where  the  track  has  burrowed  to  great  length,  much  may 
be  accomplished  by  modified  operations.  In  a  track,  for  ex- 
ample, which  has  one  opening  near  the  anus  and  another  in  the 
middle  of  the  thigh,  a  counter-opening  may  be  made  between 
the  two,  and  the  further  extremity  induced  to  heal  while  drain- 
age is  maintained  from  the  middle  opening,  by  the  use  of  injec- 
tions or  caustic  applications.  Should  these  means  not  succeed, 
and  should  it  appear  that  a  free  division  is  likely  to  result  in 
a  cure,  the  incision  may  be  made  according  to  the  ordinary  rules 
of  surgery.  Such  operations  have  been  done,  and  tracks  of 
great  length  extending  under  the  gluteal  muscles  have  been 


FlG.  46. — Enterotome  of  Richet  for  Deep  Fistulae. 

divided  with  the  ecraseur  with  good  results.  I  have  myself  fol- 
lowed a  track  directly  across  the  perineum  and  exposed  the 
membranous  urethra  in  the  incision,  dividing  in  the  operation 
the  sphincters  four  different  times.  Such  operations  may  some- 
times be  necessary  to  save  life,  but  they  may  be  too  great  for 
the  patient's  powers  of  recuperation. 

An  abscess  between  the  prostate  gland  and  the  perineum, 
where  the  pus  is  confined  by  the  perineal  fascia,  may  result  in 
both  a  rectal  and  a  urethral  fistula.  The  operation  in  such  a 
case  is  the  same  as  for  other  sinuses,  that  leading  into  the  rec- 
tum being  first  divided,  and  the  others  which  communicate  with 
it,  later. 

In  fistula  complicating  stricture  of  the  rectum,  attention 
should  always  first  be  turned  to  the  latter,  for  if  this  can  be 
cured  there  is  a  prospect  that  the  former  may  undergo  sponta- 
neous closure,  and  if  the  stricture  be  not  relieved  it  will  be  of 


ABSCESS    AND    FISTULA.  125 

little  avail  to  cut  the  fistula.  Many  awkward  mistakes  have 
happened  to  good  surgeons  by  failing  to  detect  this  complica- 
tion of  diseases. 

Throughout  this  chapter  on  the  treatment  of  fistula  I  have 
endeavored  constantly  to  keep  before  the  eye  of  the  reader  the 
importance  of  the  sphincter  muscles.  A  permanen t  incontinence 
of  faeces  is  always  considered  by  the  patient  a  very  poor  ex- 
change for  a  fistula  which  was  causing  comparatively  little 
suffering  or  annoyance. 


CHAPTER   VI. 

HEMORRHOIDS. 

Definition. — Division  into  External,  Internal,  and  Intermediate. — Differences  between 
the  two  Varieties. — External  Haemorrhoids. — Pathology. — Inflamed  Haemorrhoids. 
— Treatment. — Means  of  Prevention. — Palliative  Treatment.- — Excision. — Internal 
Haemorrhoids. — Division  into  Capillary,  Arterial,  and  Venous. — Description  of 
Capillary  Variety,  of  Venous  Variety,  of  Arterial  Variety. — Symptoms  of  Internal 
Haemorrhoids. — Strangulation. — Diagnosis.  —Treatment  of  Internal  Haemorrhoids. 
— Palliative  Treatment. — Constitutional  and  Local  Means  of  Palliation. — Treat- 
ment of  Strangulation. — Curative  Treatment. — Haemorrhoids  Associated  with 
Uterine  Disease. —Symptomatic  Haemorrhoids. — Radical  Cure. — Caustics. — Dan- 
gers of  Nitric  Acid. — Vienna  Paste. — Treatment  by  Carbolic  Acid  Injections; 
Cases  and  Cures. — Advantages  of  this  Treatment. — Treatment  by  Ligature. — 
Description  of  Operation- — Operation  with  Clamp  and  Cautery. 

Hemorrhoids  may  be  defined  as  varicosities  of  the  anal  or  rec- 
tal vessels.  They  may  present  themselves  under  various  forms 
and  conditions  owing  to  changes  in  their  substance  ;  but  the 
first  step  in  their  formation  is  always  an  enlargement  and  dila- 
tation of  the  veins  or  arteries  or  both. 

Haemorrhoids,  for  convenience,  may  be  divided  into  external 
and  internal ;  and  these  may  always  be  distinguished  from 
each  other,  though  both  may  exist  at  the  same  time  in  the  same 
patient.  An  external  hemorrhoid  originates  in  the  subcuta- 
neous veins  which  surround  the  anus  ;  it  is  therefore  entirely 
below  the  sphincter  muscle,  and  though  it  may  be  partially 
covered  by  mucous  membrane,  it  does  not  come  from  the  rectum 
proper,  nor  can  it  be  forced  above  the  external  sphincter  mus- 
cle. An  internal  hemorrhoid  originates,  on  the  other  hand, 
within  the  rectum,  and  may  exist  for  a  long  time  without  ap- 
pearing externally.  When  it  does  show  itself  outside  of  the 
anus,  it  is  a  result  of  straining,  of  increase  in  size,  or  of  a  lax 
condition  of  the  sphincter;  and  after  long  exposure  outside  the 
body  it  may  become  changed  in  character  and  appearance,  till 
the  mucous  membrane  covering  it  takes  on  something  of  the 
character  of  integument ;  but  it  may  still,  with  proper  manage- 


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HAEMORRHOIDS.  127 

ment,  be  returned  within  the  bowel,  though  it  may  not  remain 
there  for  any  length  of  time. 

The  distinction  between  an  external  and  an  internal  hemor- 
rhoid  is  not,  however,  a  purely  arbitrary  one,  the  one  being 
below,  and  the  other  above  the  external  sphincter.  A  different 
set  of  blood-vessels  is  implicated  in  each  case.  An  external 
hemorrhoid  is  a  varicosity  of  an  external  hemorrhoidal  vein, 
and  is,  therefore,  an  affection  of  the  general  venous  circulation. 
An  internal  hemorrhoid  is  a  varicosity  of  the  middle  or  internal 
hemorrhoidal  veins,  which  are  parts  of  the  visceral  venous  sys- 
tem. A  glance  at  the  venous  anatomy  of  the  rectum  and  anus 
(pages  17  and  18)  will  show  the  arrangement  of  these  two  sets 
of  veins,  and  will  also  explain  how,  from  the  free  anastomosis 
which  exists  between  them,  it  is  improbable  that  one  should  be 
affected  without  influencing  the  other  to  a  greater  or  less  extent, 
and  how,  judged  by  this  test  alone,  it  may  be  impossible  to  tell 
whether  a  particular  hemorrhoid  belongs  to  one  system  or  the 
other.  For  practical  purposes,  therefore,  the  first  definition  is 
the  better  one — an  external  hemorrhoid  is  one  originating  out- 
side of  the  external  sphincter,  and  an  internal  one  is  one  origi- 
nating within  that  muscle.  Other  secondary  differences,  which 
may  arise  from  various  causes,  in  the  development  and  location 
of  the  tumors  will  be  considered  later. 

Intermediate  Haemorrhoids. — A  third  class  of  hemorrhoids 
may  with  advantage  be  made  to  include  those  which  are  on  the 
dividing  line  between  the  external  and  internal,  partaking  some- 
what of  the  characters  of  both.     Plate  II. ,  Fig.  1. 

External  Haemorrhoids. — A  person  of  middle  age  who  has 
not  at  some  time  suffered  from  an  external  hemorrhoid  is  in- 
deed a  great  rarity,  so  common  is  this  affection.  In  the  major- 
ity of  cases,  it  is  allowed  to  run  its  own  course,  and  only  when 
the  pain  is  unusually  severe,  or  some  untoward  accident  has 
happened,  does  the  patient  consult  the  surgeon.  It  is  perhaps 
useless  to  seek  for  the  causes  of  a  malady  which  is  so  universal 
beyond  a  few  which  are  well  recognized  and  manifest.  Amongst 
these  are  straining  at  stool,  pregnancy,  affections  of  the  internal 
organs  which  interfere  with  the  return  of  venous  blood,  and 
constipation.  Outside  of  these  cases  where  a  manifest  cause 
exists,  external  hemorrhoids  will  be  found  amongst  all  classes. 
Those  who  smoke  and  those  who  do  not ;  the  high  liver  and 
the  abstemious  ;  the  laborer  and  the  professional  man  ;   those 


128  DISEASES    OF   THE    RECTUM    AND    ANUS. 

who  stand  and  those  who   sit ;    are    all   affected  and  about 
equally. 

An  external  hemorrhoid  may  appear  in  two  different  forms 

which  bear  little  resemblance  to  each  other.     The  first  is  a  small, 

round  or  elongated  venous  tumor  (Fig.  47) ;  the  second  is  a  tag 


Fig.  47.— External  Venous  Haemorrhoid.     (Smith.) 

of  hypertrophied  skin,  sometimes  improperly  spoken  of  as  a 
condyloma  (Fig.  48).  The  second  is  formed  from  the  first  by 
changes  soon  to  be  described. 

The  external  haemorrhoid  may  arise  in  either  of  two  ways, 
by  the  dilatation  of  a  vein,  or  the  rupture  of  a  vein  and  the  ex- 
travasation of  blood  into  the  adjacent  tissue.  The  dilatation 
may  not  always  be  of  the  same  character.  In  one  case  it  may 
affect  the  whole  calibre  of  the  vessel,  in  another  it  may  be  in 
the  form  of  a  pouch  springing  out  from  one  point  in  the  circum- 
ference. A  haemorrhoid  resulting  from  the  dilatation  of  a  vessel 
is  of  gradual  formation  ;  but  it  sometimes  happens,  particularly 
after  a  violent  straining  at  stool,  that  the  patient  will  feel  a 
peculiar  sensation  at  the  anus,  and  an  examination  will  reveal 
the  presence  of  a  tense,  bluish,  smooth  tumor,  the  size  of  a  pea 
or  a  grape,  situated  just  at  its  verge.     In  this  case,  a  previously 


HAEMORRHOIDS. 


129 


dilated  and  weakened  vein  has  suddenly  given  way,  and  the 
tumor  is  the  result  of  the  extravasatiou  of  blood. 

Such  a  bloody  tumor  as  this  will  cause  much  pain  and  dis- 
comfort, preventing  the  patient  from  sitting  down,  or  even  from 
going  round  with  any  ease.     It  may  be  freely  incised  by  trans- 


Fig.  48. — External  Cutaneous  Haemorrhoids.     (Esmarch.) 

fixing  its  base  with  a  small,  sharp,  curved  bistoury  and  cutting 
outward,  the  incision  being  in  the  direction  of  the  radiating 
folds  of  the  anus,  and  this  operation  is  sure  to  give  tempo- 
rary relief,  by  allowing  the  escape  of  a  small  clot  of  blood 
and  putting  an  end  to  the  tension  which  is  causing  the  suf- 
fering. 

If  the  surgeon  undertake  this  method  of  treatment,  there  are 
one  or  two  hints  which  may  be  of  value.     The  incision  itself  is 


G.TIEMANN-CO  ITC 

Pig.  49.  -  Small,  Sharp-pointed,  Curved  Bistoury. 

extremely  painful,  and  should  therefore  be  done  with  a  sharp 
knife  of  the  form  shown  in  Fig.  49,  and  it  should  be  done  in- 
stantaneously. Whatever  deliberation  is  required,  is  better  ex- 
ercised before  entering  the  knife.  Again,  care  should  be  exer- 
cised to  empty  the  clot  entirely  out  of  its  bed,  otherwise  a  small 


130  DISEASES    OF    THE    RECTUM    AXD    ANUS. 

wound  remains  which  will  not  readily  heal,  because  the  sac  is 
prevented  from  contracting,  and  the  patient  is  obliged  to  wear  a 
bandage,  perhaps  for  a  week  or  longer,  to  keep  from  soiling  the 
linen  with  a  sanious  discharge.  Under  such  circumstances  also 
the  pain  is  but  little  relieved  by  the  operation.  Again,  I  have 
in  a  few  cases  seen  the  incision  heal  by  primary  intention,  and 
the  sac  again  till  with  blood,  thus  leaving  the  patient  in  the 
same  condition,  as  regards  suffering,  as  before  operation.  This 
is  best  avoided  by  placing  a  shred  of  lint  in  the  cut.  These, 
however,  are  untoward  accidents  which  may  attend  an  insignifi- 
cant operation  which  usually  gives  relief  to  suffering,  and  al- 
lows the  tumor  to  shrivel  up  and  disappear  except  for  a  small 
tag  of  skin  which  may  remain  and  form  an  external  pile  of  the 
second  variety. 

When  left  to  its  own  course,  a  bloody  tumor  of  this  variety 
may  gradually  decrease  in  size  from  the  absorption  of  the  fluid 
elements  of  the  clot,  the  pain  decreasing  at  the  same  time;  and 
after  a  week  or  ten  days  of  discomfort,  it  is  changed  into  a 
cutaneous  hemorrhoid.  Or  the  opposite  course  may  be  taken, 
and  the  tumor  may  show  all  the  signs  of  an  abscess  (Plate  II., 
Fig.  4),  and  finally  rupture  spontaneously  with  the  discharge 
of  a  little  blood  and  pus,  and  with  an  instantaneous  ending  to  a 
week  of  suffering.  For  during  this  acute  inflammatory  process, 
the  pain  is  often  very  severe,  the  discomfort  constant,  and  there 
may  be  more  or  less  febrile  excitement,  all  of  which  will  pass 
away  the  moment  the  tension  is  relieved.  The  treatment  of 
such  a  case  where  the  knife  is  not  used  will  be  described  a  little 
later. 

To  return  to  the  hemorrhoid  which  is  due  to  the  varicose 
vein,  but  not  to  the  extravasation  of  its  contents.  In  such  a 
case  there  may  be  one  considerable  dilatation  which  shall  cause 
a  smooth,  round,  bluish  tumor  the  size  of  a  pea  or  a  grape ;  or 
there  may  be  a  number  of  veins  included  in  a  new  growth  of 
connective  tissue  which  shall  constitute  a  distinct,  firm,  hsemor- 
rhoidal  tumor.  For  these  dilated  pouches  are  in  themselves 
causes  of  irritation,  and  are  subject  to  irritation  from  without  ; 
and  as  a  result  an  exudation  takes  place  in  their  vicinity  which 
finally  ends  in  the  production  of  new  tissue.  It  is  thus  easily 
understood  why  on  cutting  into  one  external  hemorrhoid  a 
single  large  clot  will  be  exposed  contained  in  a  distinct  sac ; 
while  in  another,  several  smaller  clots  may  be  seen  imbedded  in 


HEMORRHOIDS. 


131 


the  surface  of  the  section,  and  why  there  is  more  or  less  connec- 
tive tissue  in  the  tumor.     Figs.  50  and  51. 

The  formation  of  such  a  tumor  is  a  gradual  process  due  to 
the  continuous  action  of  the  primary  cause  and  to  subsequent 
irritation  from  without.  It  may  go  on  with  little  pain  and  suf- 
fering, so  little  that  the  patient  will  hardly  care  to  ask  for  re- 
lief ;  and  it  may  undergo  a  spontaneous  cure,  leaving  in  its  place 
only  an  hypertrophied  tag  of  skin.  Generally,  however,  during 
its  course  an  attack  of  acute  inflammation  will  be  excited  at 
some  time,  and  this  is  very  apt  to  bring  the  sufferer  into  the 


Fig.  50. — External  Hemorrhoid  with  Increase  of  Connective  Tissue.     (Esmarch. ) 


Pig.  51. — External  Hsemorrhoid  after  Injection  of  the  Vein.     (Eroriep.) 

hands  of  the  surgeon.  At  such  a  time,  if  the  inflammation  has 
occurred  in  a  fleshy  pile  the  tag  will  be  swollen,  oedematous, 
and  exquisitely  sensitive.  Suppuration  may  occur  in  it  and  a 
small  marginal  abscess  and  fistula  be  the  result.  Or,  if  the  in- 
flammation has  attacked  a  sanguineous  tumor,  it  will  be  found 
hard  and  swollen  and  painful  to  the  touch.  The  patient  will 
often  say  that  he  has  tried  to  replace  the  little  grape-like  tumor 
within  the  bowel,  but  has  been  unable,  though  the  pressure  has 
caused  it  to  disappear  for  the  moment  and  has  given  a  tempo- 
rary relief.  This  is  due  to  emptying  the  vein  of  its  blood,  but 
the  blood  returns  the  moment  the  pressure  is  removed. 

The  pain  is  constant,  often  preventing  sleep  at  night.     The 


132  DISEASES    OF    THE   RECTUM    AND    A"NCTS. 

sufferer  is  "unable  to  sit  or  stand,  and  soon  finds  that  he  feels 
better  in  the  recumbent  posture.  A  motion  of  the  bowels  is 
feared  and  therefore  avoided  as  long  as  possible.  When  after 
two  or  three  da}rs  of  constipation  the  call  can  no  longer  be  de- 
layed, the  pain  is  greatly  increased.  It  is  astonishing  how  much 
pain  and  constitutional  disturbance  such  an  apparently  trivial 
thing  may  cause. 

Such  an  attack  in  a  sanguineous  hemorrhoid  may  terminate 
in  three  ways :  by  resolution,  by  induration,  and  by  suppura- 
tion. In  the  former  case  the  resolution  may  be  complete,  espe- 
cially when  the  inflammation  has  been  of  moderate  intensity,  and 
no  trace  of  the  tumor  may  remain,  or  a  cutaneous  tag  may  be 
left  to  mark  its  former  site,  When  the  inflammation  assumes 
a  chronic  type,  and  the  tumor  becomes  cedematous,  and  is  still 
somewhat  painful  on  pressure  or  during  defecation,  though  not 
to  such  a  degree  as  during  the  acute  stage,  the  inflammation  is 
said  to  have  terminated  in  induration.  Such  a  tumor  is  always 
liable  on  slight  provocation  to  a  fresh  attack  of  inflammation. 
When  suppuration  occurs,  the  tumor  discharges  its  pus  and 
then  shrivels  up  and  becomes  a  cutaneous  tag. 

Treatment. — The  surgeon  will  seldom  be  called  upon  to  treat 
a  case  of  external  haemorrhoids  unless  during  an  attack  of  acute 
inflammation  ;  for  at  other  times  the  annoyance  caused  by  them 
is  comparatively  trivial.  A  cutaneous  tag  which  is  quiescent 
may  as  well  be  left  undisturbed  by  the  knife  or  scissors  ;  for  the 
removal  of  it  will  not  infrequently  cause  an  amount  of  suffering 
disproportionate  to  the  benefit  gained.  The  whole  thought  of 
the  surgeon  may  then  be  turned  first  to  the  prevention  and 
second  to  the  relief  of  an  attack  of  inflammation.  The  means 
of  prevention  are  very  simple  and  yet  very  effectual.  They  con- 
sist In  the  avoidance  of  excess  in  eating  or  drinking,  and  in  per- 
fect regularity  in  defecation  ;  for  in  a  person  affected  with  ex- 
ternal haemorrhoids  a  single  heavy  meal  at  an  unusual  hour,  an 
evening  spent  iri  smoking  and  drinking,  or,  worst  of  all,  the 
neglect  to  have  a  motion  of  the  bowels  for  a  single  day,  will  give 
rise  to  a  sensation  of  heat,  pressure,  and  itching  about  the  anus, 
which  warns  him  that  trouble  has  commenced.  Even  under 
sucb  circumstances  the  attack  may  be  aborted  by  rest  in  the 
recumbent  attitude,  a  light  diet,  abstinence  from  wine  or  liquor 
of  any  kind,  and  a  laxative,  preferably  one  of  the  mineral 
waters,  repeated  every  night  for  three  or  four  days. 


HEMORRHOIDS.  133 

Should  the  attack  go  on  and  actual  inflammation  be  excited, 
more  active  treatment  will  be  required,  and  this  may  be  either 
operative  or  medicinal.  It  is  my  own  practice  to  try  the  latter 
first,  and  if  it  does  not  succeed,  resort  to  the  former.  The  me- 
dicinal treatment  consists  in  keeping  the  sufferer  on  the  bed  or 
lounge,  and  applying  a  small  bladder  of  pounded  ice  to  the 
part.1  This  is  generally  very  grateful  to  the  patient  and  very 
effectual — much  more  so  than  warm  poultices  or  applications  of 
belladonna  and  opium  ;  but  should  it  not  prove  so,  the  latter 
may  be  tried.  A  good  formula  is  equal  parts  of  the  extract  of 
belladonna  and  opium  smeared  freely  over  the  anus.  In  most 
cases  the  attack  will  subside  after  forty-eight  hours  of  this  treat- 
ment, and  the  use  of  a  daily  laxative  ;  but  should  it  not,  a  san- 
guineous tumor  maybe  incised  in  the  manner  already  described, 
and  a  cutaneous  tag  may  be  seized  with  a  sharp  forceps  and 
quickly  snipped  off  with  the  scissors.  Ether  is  not  generally 
necessary  for  this  operation,  which,  though  very  painful,  re- 
quires but  a  moment ;  and  I  have  generally  found  that  attempts 
at  local  anaesthesia  with  the  ether  spray  were  very  delusive  on 
this  part  of  the  body.  If  ether  be  employed  at  all,  it  is  much 
better  to  take  advantage  of  the  primary  anaesthesia  produced  by 
the  first  few  inhalations,  the  patient  holding  the  towel  or  bottle 
in  his  or  her  own  hand.  This  is  a  favorite  procedure  of  my  own 
in  this  and  many  other  operations  about  the  anus,  and  one 
which  I  cannot  too  strongly  recommend. 

The  only  caution  necessary  in  cutting  off  an  external  haemor- 
rhoid  is  to  remove  neither  too  much  nor  too  little  tissue.  If 
too  much  be  removed,  the  wound  will  take  a  long  time  to  heal, 
and  if  several  tumors  be  removed,  contraction  to  a  disagreeable 
extent  may  follow  ;  if  too  little,  a  tag  of  skin  will  still  remain 
after  cicatrization  and  shrinking,  and  although  this  might  be 
considered  a  matter  of  no  importance  in  a  male  patient,  I  have 
seen  ladies  who  did  not  so  consider  it. 

Internal  Hcemorrhoids . — External  haemorrhoids  were  de- 
scribed as  varicosities  of  the  external  haemorrhoidal  veins  ;  and 
internal  haemorrhoids  may  also  be  similarly  defined  as  varicosi- 
ties of  the  middle  and  superior  haemorrhoidal  veins,  but  they 
are  more  than  this.  An  internal  haemorrhoid  is  often  an  arte- 
rial tumor,  as  well  as  a  venous,  and  the  arteries  may  be  of  large 

1  Nothing  is  so  convenient  for  this  purpose  or  causes  as  little  pain  as  the  rubber 
baudruche,  which  may  now  be  procured  at  any  druggist's. 


134 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


size  (Fig.  52).  Occasionally  one  will  be  met  as  large  as  the 
radial.  In  describing  these  tumors,  we  shall  follow  the  division 
laid  down  by  Allingham  into  capillary,  arterial,  and  venous. 

The  capillary  hemorrhoid  is  in  reality  an  erectile  tumor, 
composed  of  the  terminal  branches  of  the  arteries  and  veins  and 
of  the  capillaries  which  join  them.  This  form  of  tumor  is  never 
of  large  size,  and  never  projects  very  far  into  the  cavity  of  the 
rectum.      To  the  naked  eye  and  under  the   microscope  they 


Fig.  52. — Internal  Haemorrhoids  showing  Line  of  Junction  of  the  Skin  and  Mucous  Mem- 
brane.   (Curling. ) 

strongly  resemble  an  arterial  naBvus.  They  may  be  situated 
high  up  in  the  rectum  or  low  down  by  the  sphincter ;  their  sur- 
face is  granular,  and  the  membrane  covering  them  is  always  of 
extreme  thinness.  This  accounts  for  the  chief  symptom  which 
distinguishes  them  clinically  from  the  other  varieties— the  free 
arterial  haemorrhage  which  follows  the  slightest  bruising  of 
their  surface  even  in  the  act  of  defecation.  Such  a  tumor  never 
appears  outside  of  the  anus  unless  accompanied  by  some  other 
rectal  affection,  but  it  may  sometimes  be  seen  by  a  careful  pull- 
ing open  of  the  sphincter  with  the  fingers,  and  from  some  part 
of  its  strawberry-like  surface  there  is  pretty  sure  to  be  a  jet  of  ar- 
terial blood,  coming  per  saltern.    The  disturbance  caused  by  the 


HAEMORRHOIDS.  135 

gentlest  examination  is  sufficient  to  start  this  bleeding,  and  it 
almost  always  occurs  at  defecation.  This  is  the  form  of  haemor- 
rhoid  to  which  the  name  of  ''bleeding"  most  properly  applies. 
In  my  own  experience  it  is  not  as  frequently  met  with  as  the 
varieties  to  be  described  later ;  and  this  probably  for  the  reason 
that  after  existing  for  a  longer  or  shorter  period  in  this  form  it 
is  changed  into  one  of  the  others  ;  and  that  patients  do  not  seek 
relief  till  after  such  change  has  occurred.  After  a  time,  the 
mucous  membrane  covering  such  a  tumor  becomes  thickened, 
and  as  a  result  of  repeated  irritation,  there  is  an  increase  in  the 
submucous  tissue.  The  haemorrhage  decreases  in  frequency 
and  finally  ceases  as  the  capillaries  become  obliterated  by  the 
increase  in  the  connective  tissue,  and  the  capillary  tumor  is  suc- 
ceeded by  the  arterial  or  the  venous  one. 

The  one  symptom  of  a  capillary  haemorrhoid  is  the  daily 
haemorrhage ;  and  as  this  haemorrhage  occurs  at  the  time  of 
defecation,  and  there  is  no  pain  at  any  time,  the  patient  may  be 
entirely  ignorant  of  the  fact  that  blood  is  daily  lost.  This  is 
particularly  the  case  with  the  class  of  patients  seen  in  public 
practice  who  give  little  attention  to  themselves.  In  the  higher 
walks  of  life  such  a  loss  of  blood  seldom  occurs  without  the 
knowledge  of  the  patient ;  but  unfortunately  it  is  often  disre- 
garded, especially  in  women,  who  are  in  the  habit  of  losing 
blood  at  every  menstrual  turn  and  who  always  shrink  from  an 
examination. 

It  is  not  necessary  to  relate  in  detail  the  train  of  constitu- 
tional symptoms  which  may  follow  the  daily  loss  of  a  con- 
siderable quantity  of  arterial  blood.  The  anaemic  look,  the 
disturbance  of  the  heart's  action,  the  troubles  with  the  digestive 
apparatus  and  with  the  sexual  organs,  the  cessation  of  menstru- 
ation, are  all  well  known.  But  it  is  curious  that,  as  in  a  recent 
case  in  my  own  practice,  a  very  intelligent  medical  man,  who 
understood  perfectly  his  own  condition,  should  allow  himself 
to  be  brought  to  a  state  of  profound  anaemia  by  a  little 
haemorrhoid  of  this  variety  rather  than  have  anything  done  for 
himself.  In  this  case  a  single  application  of  nitric  acid  to 
the  bleeding  surface  worked  a  cure  which  has  lasted  for  several 
years. 

The  Arterial  Hemorrhoid. — In  this  form  of  tumor  the 
capillary  network  has  disappeared  and  in  its  place  is  found  a 
mass  of  freely  anastomosing  arteries  and  veins  bound  together 


136  DISEASES    OF    THE    RECTUM    AND    ANUS. 

by  connective  tissue.  The  arteries  and  the  veins  are  tortuous, 
often  varicose  and  dilated  into  sacs  and  pouches,  and  the 
arteries  may  be  of  large  size,  especially  the  one  which  enters  at 
the  base  of  the  tumor,  the  pulsations  of  which  may  often  be 
distinctly  felt  by  the  finger.  Such  a  tumor  is  often  of  consider- 
able size  ;  it  is  firm  to  the  touch  and  smooth  ;  it  is  liable  to 
inflammation,  erosion,  haemorrhage,  and  prolapse.  The  haemor- 
rhage which  occurs  is  arterial  in  character,  and  apt  to  be  abun- 
dant. When  the  hemorrhoid  has  gained  a  sufficient  size  to 
become  prolapsed  in  the  act  of  defecation,  the  patient  suffers 
the  usual  symptoms  of  the  hemorrhoidal  state.  If  the  sphincter 
be  not  tight  enough  to  strangulate  the  mass  after  it  has  come 
out  of  the  body,  the  pain  will  not  be  very  severe  and  the 
patient  will  return  the  tumor  by  a  little  gentle  pressure  and 
manipulation. 

The  Venous  Hemorrhoid. — This  form  of  haemorrhoid  may 
result  from  either  of  those  already  named  or  it  may  arise  de 
novo.  It  consists  at  first  of  a  simple  dilatation  of  the  large  veins 
beneath  the  mucous  membrane  of  the  rectum  ;  later  these  veins 
undergo  certain  changes  due  to  the  hypertrophy  and  induration 
of  the  mucous  membrane  and  submucous  connective  tissue, 
until  finally  a  large,  bluish,  hard  tumor  is  formed  which  is 
smooth  to  the  touch,  comes  out  of  the  body  on  defecation,  and 
is  covered  by  a  mucous  membrane  which  has  assumed  a  par- 
tially cutaneous  character  from  exposure. 

The  three  varieties  of  internal  haemorrhoids  thus  described 
may  all  be  present  in  the  same  person,  and  each  be  distinguish- 
able from  the  other.  In  other  cases  the  line  of  distinction  may 
not  be  so  well  marked.  A  venous  haemorrhoid  may  contain  a 
considerable  number  of  arteries  and  may  bleed  per  saltern,  and 
it  is  not  certain  that  an  arterial  haemorrhoid  is  always  a  later 
stage  of  the  capillary  variety.  But  the  three  forms  are  well 
marked  and  must  be  distinguished  from  each  other  in  the 
matter  of  treatment. 

Symptoms.—  Usually  the  first  symptom  of  internal  haemor- 
rhoids is  the  loss  of  blood  during  defecation,  to  which  reference 
has  already  been  made.  This  may  be  present  for  a  long  time 
before  any  other  symptom  is  noticed  by  the  patient,  except 
perhaps  an  occasional  feeling  of  discomfort  in  the  rectum,  and  a 
sensation  that  the  rectum  has  not  been  thoroughly  emptied 
after    stool.     There  is  however  a  peculiar   train   of    nervous 


HAEMORRHOIDS.  137 

symptoms  which  are  quite  characteristic  of  the  disease,  and 
which  may  be  well  marked  before  either  bleeding  or  protrusion 
has  appeared.  These  are  difficulty  in  micturition,  diminished 
sexual  power  and  desire,  pain  in  the  genitals,  loins,  and  thighs, 
and  formication  in  the  lower  extremities.  A  very  marked  case 
of  this  last  symptom  was  sent  to  me  not  long  since  by  Dr. 
Spitzka.  The  patient  was  himself  a  very  intelligent  physician, 
who  had  consulted  Dr.  Spitzka  for  supposed  incipient  locomotor 
ataxia,  but  no  disease  of  the  spine  being  found  he  was  referred 
to  me  for  rectal  examination,  under  the  suspicion  that  a  disease 
of  this  part  might  account  for  the  condition.  Such  was  found 
to  be  the  fact,  there  being  well-marked  hgemorrhoidal  trouble 
wiiich  had  never  manifested  itself  in  any  other  way,  except  by 
a  slight  uneasiness  after  defecation. 

Pain  in  the  rectum  of  a  sharp  lancinating  character  may  be 
present  as  an  early  symptom,  but  it  is  not  generally  complained 
of  until  the  tumor  begins  to  descend  within  the  grasp  of  the 
sphincter  and  appears  at  the  anus  at  each  act  of  defecation.  If 
the  sphincter  be  firm  and  strong,  it  is  then  apt  to  be  very  severe 
and  the  tumor  may  become  strangulated,  but  after  the  disease 
has  existed  for  any  great  length  of  time,  and  especially  in  per- 
sons past  middle  life,  there  is  apt  to  be  a  loss  of  power  in  the 
muscle  which,  though  it  facilitates  prolapse,  decreases  the  pain 
attendant  upon  it. 

It  will  occasionally  happen  that  internal  haemorrhoids 
though  fully  developed  and  of  many  years'  standing  have  never 
been  known  by  the  patient  to  cause  any  loss  of  blood  though 
such  a  case  is  very  rare. 

In  ordinary  cases,  the  patient  will  reduce  the  tumors  when 
they  come  down  on  defecation.  They  may,  however,  become 
strangulated,  and  be  entirely  beyond  the  patient's  power  of 
manipulation.  In  such  a  case,  after  a  period  of  rest,  and  after 
the  relief  which  may  follow  a  spontaneous  escape  of  blood  from 
the  over-distended  vessels,  the  haemorrhoids  may  return  of 
themselves  or  be  put  back  by  the  patient. 

If  the  strangulation  be  more  intense,  gangrene  may  set  in 
and  a  part  of  the  mass  may  slough ;  or  a  part  may  suppurate 
and  pus  be  discharged.  Under  these  circumstances  there  will 
be  great  pain  and  more  or  less  constitutional  disturbance,  with 
fever  and  loss  of  appetite.  The  gangrene  is  very  evident  to  the 
eye  from  the  greenish  or  blackish  color  and  fetid  odor  of  the 


138  DISEASES    OF    THE    RECTUM    AND    ANUS. 

part,  and  is  rather  a  favorable  termination  to  the  trouble,  as  it 
generally  results  in  a  radical  cure. 

Diagnosis. — It  is  not  always  an  easy  matter  to  discover  an 
internal  hsemorrhoid,  even  though  it  be  far  enough  advanced  to 
cause  haemorrhage  and  more  or  less  uneasiness.  When  it  has 
become  hard,  it  may  be  detected  by  the  accustomed  finger  in  a 
simple  digital  examination,  but  when  soft  and  not  over-dis- 
tended, it  may  escape  detection.  An  examination  should  be 
made  directly  after  the  rectum  has  been  emptied  by  an  enema 
of  warm  water,  when  the  water  and  the  straining  have  brought 
it  into  prominence,  and  should  be  made  with  a  speculum  when 
there  is  any  doubt.  Under  these  circumstances  it  may  gener- 
ally be  brought  plainly  into  view.  An  examination  in  a  case  of 
internal  haemorrhoids  should  never  end  at  the  finding  of  the 
tumor.  An  inch  or  so  higher  up  there  may  be  a  stricture, 
malignant  or  simple,  which  has  given  no  sign  of  its  presence 
except  the  haemorrhoids,  and  this  is  not  a  good  thing  to  over- 
look. 

Treatment. — The  treatment  of  this  most  common  and  dis- 
tressing malady  may  with  advantage  be  considered  under  two 
different  heads — (a)  palliative,  (b)  radical. 

(a)  Tlie  Palliative  Treatment  of  Internal  Haemorrhoids. — 
In  spite  of  all  that  the  surgeon  may  say  to  his  patient  of  the 
advantages  of  a  radical  cure,  and  the  safety  and  facility  with 
which  it  may  be  accomplished,  he  will  still  have  many  more 
chances  in  the  way  of  palliation  than  will  fall  to  him  of  using 
the  knife.  It  is,  therefore,  of  great  advantage  to  know  what 
can  be  done  for  a  timid  and  reluctant  sufferer  without  the  knife  ; 
and,  indeed,  most  patients  may  be  made  greatly  more  comfort- 
able without  any  surgical  interference  whatever. 

The  first  thing  to  be  done  is  to  secure  a  daily  natural  evacu- 
ation of  the  bowels,  and  this  without  medicine,  if  possible.  The 
diet  should  be  plain  and  abundant.  Highly  seasoned  meats, 
gravies,  salads,  old  cheese,  etc.,  all  alcoholic  drinks,  and  any- 
thing approaching  excess  in  tobacco,  should  be  strictly  inter- 
dicted. If  the  bowels  do  not  act  daily  with  this  diet,  and  with 
regularity  in  the  time  of  going  to  the  closet,  a  laxative  must  be 
added,  and  this  may  be  either  in  the  form  of  a  mineral  water  in 
the  morning,  or  of  a  small  dose  of  compound  licorice  powder  at 
night. 

This  powder  may  now  be  bought  under  that  name  at  most 


H^EMOKEHOIDS.  139 

drug  stores.     The  formula  is,  however,  appended  for  the  con- 
venience of  any  who  may  desire  it : 

3 .  Fol.  sennae 2  parts. 

Had.  liquiritiae 2  parts. 

Fruct.  foeniculi  pulv 1  part. 

Sulphuris  depurati = 1  part. 

Sacch.  pulv 6  parts. 

If  the  haemorrhoids  are  in  the  habit  of  coming  down  when 
the  patient  has  a  passage,  he  must  accustom  himself  for  a  time 
to  the  use  of  a  bed-pan,  and  to  having  his  passages  while  in  the 
horizontal  position.  This  will  be  considered  a  very  objection- 
able remedy  by  most ;  but  it  is  one  from  which  great  benefit  will 
be  derived. 

The  other  treatment  is  local,  and  consists  mainly  in  the  use 
of  astringents  and  of  cold.  A  cold  sitz-bath  every  morning  is 
one  of  the  best  of  all  methods  of  preventing  and  relieving  haem- 
orrhoids ;  and  after  each  passage  cold  water  should  be  freely 
applied  to  the  protruding  mass.  Even  ice-water  will  do  no 
harm,  and  if  the"  case  is  one  attended  with  bleeding,  this  will 
be  found  a  most  valuable  means  of  combating  that  symptom. 
The  number  of  astringents  which  have  been  recommended  for 
use  under  the  circumstances  we  are  now  considering  is  very 
large.  I  shall  content  myself  with  naming  one,  the  subsulphate 
of  iron,  which  combines  the  advantages  of  all  the  others.  This 
may  be  applied  in  the  form  of  an  ointment  (3  ]'.-§].)  to  the 
haemorrhoids  when  prolapsed,  or  may  be  given  in  the  form  of  a 
suppository  (2-5  grs.)  and  allowed  to  remain  in  the  rectum  over 
night.  It  will  be  found  to  act  simply  as  an  astringent,  causing 
no  pain,  and  destroying  no  tissue. 

By  these  means,  when  followed  with  care  and  patience,  the 
worst  case  of  haemorrhoids  ma}7  be  greatly  improved,  and  when 
the  sufferer  will  not  submit  to  curative  treatment,  or  when,  from 
any  reason,  operative  interference  is  contra-indicated,  they 
should  always  be  tried.  Although  they  are  given  simply  as 
palliative  measures,  and  should  be  considered  as  such,  I  have 
had  some  cases  where,  after  a  few  weeks  of  this  treatment,  the 
patients  believed  themselves  cured,  and  were,  at  all  events,  so 
far  relieved  as  to  disappear  from  observation. 

Treatment  of  Strangulation. — The  practitioner  may  at  any 


1-iO  DISEASES    OF   THE    RECTUM    AND    ANUS. 

time  be  called  upon  to  treat  this  complication  of  internal  haem- 
orrhoids, and  the  condition  is  an  exceedingly  painful  one.  He 
will  generally  find  his  patient  in  bed,  complaining  that  his  piles 
are  "down,"  and  that  he  has  been  unable  to  replace  them. 
The  prolapse  may  have  occurred  at  the  time  of  defecation,  or 
during  a  momentary  mental  excitement  or  physical  effort.  On 
examination,  the  anus  will  be  seen  to  be  surrounded  with  a 
mass  of  haemorrhoids  which  are  swollen,  congested,  livid,  and 
more  or  less  cedematous,  and  any  attempt  to  replace  them  will 
cause  exquisite  pain.  This  is  an  excellent  opportunity  for  in- 
ducing the  sufferer  to  submit  to  a  radical  operation,  and  should 
consent  be  gained,  ether  may  be  given,  and  the  usual  operation, 
by  the  ligature,  be  at  once  performed.  The  operation,  under 
these  circumstances,  does  not  seem  to  be  contra-indicated,  and  I 
have  never  had  occasion  to  regret  performing  it. 

But  should  an  operation  be  refused,  the  mass  must  be  re- 
duced. The  patient  should  be  turned  on  the  face,  with  a  hard 
pillow  under  the  pelvis  to  raise  the  buttocks  and  allow  of  gravi- 
tation of  the  abdominal  contents  away  from  the  rectum.  The 
mass  should  then  be  well  smeared  with  olive  oil,  and  a  gentle 
effort  made  to  reduce  it  by  the  taxis.  This  may  sometimes  be 
done  by  introducing  one  finger  into  the  anus  and  exerting  press- 
ure with  the  others,  gradually  forcing  the  tumors,  one  by  one, 
within  the  bowel ;  at  other  times  the  mass  may  be  replaced  by 
a  firm  and  continuous  pressure,  with  the  bulbs  of  all  the  fingers 
directly  upon  it,  till  the  blood  has  been  crowded  back,  and  the 
diminished  piles  slip  up  together.  Much  gentleness  is  required 
for  this  manoeuvre,  which  is  a  very  painful  one  under  any  cir- 
cumstances, and  one  man  may  succeed  where  another  would 
fail. 

At  times,  however,  replacement  by  the  taxis  is  impossible. 
Under  such  circumstances,  it  is  a  not  uncommon  practice  to  re- 
sort to  leeches  ;  and  though  I  have  never  done  it,  I  have  seen  it 
almost  immediately  successful  with  others,  and  the  patient  him- 
self will  assure  you  that,  if  the  piles  would  only  bleed,  they 
could  be  easily  reduced.  It  is  better,  however,  to  apply  cold, 
and  to  leave  the  patient  in  bed  on  his  face,  with  the  buttocks 
raised.  The  cold  should  be  in  the  form  of  an  ice-bag,  and  this 
will  almost  certainly  give  relief  to  suffering,  and  so  reduce  the 
(Edematous  swelling  as  to  render  reduction  possible  on  a  second 
attempt.     Should  this  also  fail,  there  is  nothing  to  do  but  to 


HAEMORRHOIDS.  141 

wait  for  the  condition  to  subside  under  the  use  of  cold  and  ap- 
plications of  belladonna  and  opium  in  the  form  of  a  soft  oint- 
ment, with  rest  in  the  position  named,  and  the  administration 
of  laxatives.  After  forty-eight  hours  of  this  treatment,  the 
patient  will  generally  succeed  by  himself  in  reducing  the  mass. 

(5.)  Curative  Treatment. — Before  recommending  anything  in 
the  way  of  a  surgical  operation,  the  surgeon  must  consider 
whether  the  case  before  him  is  one  in  which  such  a  procedure  is 
justifiable,  and  this  brings  us  to  the  consideration  of  what  have 
been  called  symptomatic  haemorrhoids,  as  distinguished  from 
those  which  are  apparently  idiopathic. 

Internal  haemorrhoids  may  be  symptomatic  of  disease  in  a 
number  of  the  viscera.  They  often  indicate  structural  changes 
in  the  wall  of  the  rectum  itself  at  a  higher  point,  such  as  malig- 
nant and  non-malignant  stricture  ;  and,  under  such  circum- 
stances, whatever  is  done  in  the  way  of  relief  must  be  done  to 
the  stricture,  and  not  to  the  haemorrhoids.  Again,  they  are 
often  secondary  to  disease  of  the  bladder,  to  enlarged  prostate, 
or  to  stricture  of  the  urethra,  and  in  these  cases  where  it  is  pos- 
sible to  remove  the  cause  it  must  always  be  done.  If  haemor- 
rhoids are  dependent  upon  a  calculus  or  a  stricture  of  the 
urethra,  they  will  probably  disappear  when  these  affections  are 
cured.  I  was  consulted  not  long  since  by  a  brother  practitioner 
in  regard  to  a  very  typical  external  sanguineous  haemorrhoid 
— the  size  of  a  large  pea — on  the  person  of  his  four-year  old 
child.  The  child  had  an  adherent  prepuce,  and  the  pile  was  the 
result  of  the  straining.  The  ordinary  operation  of  circumcision 
cured  the  haemorrhoid.  A  man  with  enlarged  prostate  is  never 
a  very  desirable  subject  for  a  surgical  operation,  and  if  such  a 
man's  haemorrhoids  can  be  rendered  endurable  by  the  palliative 
treatment  already  described,  the  better  way  will  be  not  to  use 
the  knife. 

In  women  haemorrhoids  often  depend  upon  disease  of  the 
uterus,  and  in  every  female  patient  this  dependence  should  be 
carefully  inquired  into,  and  if  found,  removed  before  operation. 
The  operator  in  rectal  surgery  may  save  himself  much  discredit 
by  postponing  his  operation  for  piles  till  his  patient  has  been 
cured  of  a  uterine  displacement ;  for,  as  a  rule,  the  co-existence 
of  the  latter  disease  will  prevent  a  favorable  issue  to  the  opera- 
tion. Either  the  wounds  will  not  heal  readily,  or  the  haemor- 
rhoids will  speedily  return.     It  will  occasionally  happen  that  a 


142  DISEASES    OF    THE    RECTUM    AND    ANUS. 

pregnant  woman  will  suffer  so  severely  from  this  complication 
as  to  demand  surgical  aid.  Though  it  is  better  not  to  operate, 
except  in  a  case  where  the  haemorrhage  or  the  pain  renders  it 
unavoidable,  still,  pregnancy  is  not  an  absolute  barrier  to  sur- 
gical interference  in  this  more  than  in  many  other  affections. 

Haemorrhoids  may  also  be  symptomatic  of  disease  of  the 
liver,  kidney,  heart,  or  lungs.  There  are  few  liver  affections 
which  need  prevent  operative  interference  in  a  bad  case,  but 
such  interference  should  be  preceded  by  general  treatment  point- 
ing toward  relief  of  the  hepatic  circulation.  An  excess  of  alco- 
hol in  the  daily  diet  should  be  stopped,  and  a  blue  pill  may  be 
given  with  advantage  every  other  day  for  a  week  before  the 
operation.  Affections  of  the  lungs,  except  in  a  very  advanced 
stage,  need  not  prevent  an  operation.  The  condition  which 
most  positively  stays  the  hand  of  the  operator  is  that  of  albu- 
minuria, whether  dependent  upon  heart  or  kidney. 

Having  decided  to  attempt  a  radical  cure,  the  surgeon  finds 
himself  embarrassed  with  the  number  of  operative  procedures 
from  which  he  may  choose.  It  is  safe  to  say  that  no  one  opera- 
tion is  the  best  in  all  cases,  and  I  shall  make  no  attempt  even 
to  enumerate  all  of  those  which  have,  at  different  times,  been 
advocated,  but  shall  describe  several  which  are  to  be  relied 
upon,  and  which,  together,  will  cover  every  case. 

T/ie  Application  of  Caustics. — Chief  among  the  caustics  used 
for  this  purpose  are  nitric  acid,  pure  carbolic  acid,  and  Vienna 
paste.  The  capillary  haemorrhoid  may  be  cured  by  painting  it 
once  or  twice  with  pure  nitric  or  carbolic  acid  ;  but  large  and 
old  haemorrhoids  are  not  curable  by  this  means,  though  the 
haemorrhage  from  them  may  be  stopped,  and  for  a  time  they 
may  cease  to  prolapse.  When  used  upon  a  capillary  growth,  a 
speculum  must  be  introduced.  If  used  in  a  case  of  large  tu- 
mors, they  must  first  be  brought  outside  of  the  body,  carefully 
dried,  and  then  thoroughly  covered  with  the  acid,  applied  with 
a  small  stick  or  glass  brush.  The  end  of  a  match  makes  an  ex- 
cellent brush.  The  tumors  should  then  be  well  oiled  and  re- 
placed. The  application  is  not  generally  painful,  unless  the 
acid  is  applied  to  the  wrong  surface,  viz.,  the  skin. 

I  have  used  this  plan  of  treatment  in  many  cases  ;  have  seen 
an  exhausting  haemorrhage  from  a  capillary  tumor  stopped  for- 
ever by  a  single  application,  and  have  benefited  old  cases  to  an 
extent  which  convinced  the  patients  they  were  radically  cured 


HAEMORRHOIDS.  143 

in  spite  of  my  own  skepticism  ;  but  it  is  never  safe  to  promise 
anything  more  than  temporary  relief  by  this  means.  The  capil- 
lary tumor  is  very  likely  to  subsequently  become  the  larger  ar- 
terial one  ;  and  the  old  and  large  hemorrhoid  is  more  than  likely 
to  become  prolapsed  at  some  future  date ;  so  that  I  no  longer 
use  it  in  these  latter  cases  when  the  patient  will  permit  me  to 
follow  my  own  judgment. 

There  is  one  danger  in  the  application  of  a  strong  acid  to 
an  old  prolapsing  hemorrhoid,  and  that  is,  the  occurrence  of 
a  profuse  secondary  haemorrhage  when  the  slough  separates. 
Such  an  accident  is  not  common,  but  it  may  be  a  fatal  one,  and 
it  happens  just  often  enough  to  worry  the  surgeon  in  every  case 
in  which  he  has  employed  this  method  on  an  old  and  debili- 
tated subject. 

The  Vienna  paste  is  a  much  more  powerful  caustic  than  nitric 
acid,  and  its  application  to  the  surface  of  a  hsemorrhoid  is  very 
painful.  This  and  the  amount  of  tissue  destroyed  by  it  are  the 
two  great  objections  to  its  use.  It  has  been  employed  to  pro- 
duce deep,  linear  radiating  cicatrices,  each  cicatrix  running  from 
the  centre  of  the  anus  over  the  top  of  a  prolapsed  hsemorrhoid  ; 
and  three  or  four  such  cauterizations  will  undoubtedly  cure  an 
ordinary  case  of  piles;  but  the  Paquelin  cautery  will  do  it 
much  better,  and  if  the  patient  will  submit  to  the  latter,  he  will 
submit  to  something  better  still,  and  that  is  the  ligature. 

Treatment  by  Injection. — The  treatment  of  haemorrhoids  by 
injection  of  certain  substances,  chief  of  which  is  carbolic  acid, 
may  now,  I  believe,  be  accepted  as  a  surgical  procedure  of  a 
certain  definite  value,  and  one  worthy  of  a  place  among  the 
recognized  means  of  cure  at  our  command.  Originating  as  it 
did  among  the  quacks,  it  has  been  looked  upon  with  suspicion, 
and  its  adoption  by  the  profession  has  been  followed  by  the  ac- 
cidents which  generally  attend  a  new  remedy  before  its  applica- 
bility is  fully  understood ;  but  this  does  not  diminish  its  real 
value. 

I  wish  now  to  emphasize  what  I  wrote  in  the  first  edition  of 
this  work  in  favor  of  this  method  of  treatment.  For  the  past 
year  I  have  treated  nearly  every  case  of  internal  haemorrhoids 
for  which  I  have  been  consulted  by  this  method  alone,  and  the 
favorable  view  I  then  held  regarding  it  has  only  been  confirmed 
by  subsequent  experience. 

The  following  cases,  selected  from  dispensary  and  private 


144  DISEASES    OF    THE    RECTUM    AND    ANUS. 

practice  in  which  this  plan  of  treatment  has  been  adopted,  will 
illustrate  some  of  its  advantages  and  disadvantages. 

Case*. — Male,  aged  thirty-nine.  This  was  an  ordinary  case 
of  prolapsing  internal  haemorrhoids  of  about  six  months'  dura- 
tion in  an  otherwise  healthy  man.  The  tumors  were  well  de- 
veloped, bled  freely  at  each  motion  of  the  bowels,  and  were 
usually  reduced  by  the  patient  without  much  difficulty.  In  the 
course  of  three  months  four  injections  of  carbolic  acid  were 
made  into  four  separate  tumors.  Only  one  of  them  was  fol- 
lowed by  any  pain  or  soreness,  and  this  not  very  marked  in 
character ;  and  after  three  months  the  man  was  discharged 
cured,  there  being  no  longer  any  bleeding  or  descent  of  the 
haemorrhoids  at  defecation.  The  man,  who  was  a  fireman,  was 
at  no  time  during  the  treatment  unable  to  attend  to  the  active 
duties  of  the  service. 

Case. — Male,  aged  thirty-eight.  In  this  patient  anything 
like  a  cutting  operation  was  out  of  the  question.  He  had  been 
a  hard  drinker  for  years,  and  was  suffering  from  phthisis, 
cirrhosis  of  the  liver,  and  albuminuria.  The  haemorrhoids  were 
of  long  standing ;  the  whole  circle  of  mucous  membrane  pro- 
lapsed with  them  ;  and  the  sphincter  had  lost  its  contractile 
power.  The  man  was  under  treatment  three  months,  and  dur- 
ing that  time  six  injections  of  carbolic  acid  were  made,  and  each 
one  was  followed  by  more  or  less  pain  and  by  sloughing  of  the 
haemorrhoid.  The  pain  was  not,  however,  so  great  as  to  coun- 
terbalance the  relief  the  patient  experienced  from  the  cessation 
of  the  bleeding  and  the  decrease  in  the  protrusion,  and  the 
treatment  was  gladly  persisted  in  by  him,  till  in  the  end  he 
considered  himself  as  cured  and  ceased  to  attend.  I  have  no 
doubt  that  in  this  case  the  sloughing  of  the  tumor,  which  each 
time  left  a  dirty  sore  after  the  introduction  of  the  acid,  was  di- 
rectly due  to  the  patient's  condition  ;  but  he  was  sustained  with 
generous  diet  and  suitable  tonics,  and,  as  I  say,  did  very  well — 
much  better  than  he  would  have  done  by  any  other  plan  of 
treatment  which  it  was  safe  to  try;  and,  but  for  it,  I  should 
have  confined  myself  strictly  to  palliative  measures. 

Case. — Male,  aged  fifty-two.  General  health  excellent. 
Haemorrhoids  well  developed  and  prolapsing.  Having  had  con- 
siderable experience  with  this  method  of  treatment  by  this  time 
in  dispensary  practice,  I  ventured  to  try  it  in  a  private  patient, 
and  to  promise  an  easy  and  painless  cure.     A  single  injection 


HAEMORRHOIDS.  145 

was  therefore  made,  and  for  the  first  forty-eight  hours  there  was 
little  trouble  ;  but  at  the  end  of  that  time  I  received  a  telegram 
from  the  gentleman  that  he  was  suffering  great  and  constantly 
increasing  pain — he  having  left  me  on  the  day  following  the  in- 
jection to  return  to  his  home  in  a  neighboring  city.  I  went  to 
him  and  found,  to  my  disgust,  that  the  injection  had  in  his  case 
also  caused  a  slough,  and  that  he  was  suffering  intense  pain  at 
each  act  of  defecation.  Suitable  treatment  with  laxatives  and 
anodyne  suppositories  was  at  once  instituted,  but  his  sufferings 
continued  for  many  days,  and  he  finally  went  off  to  the  moun- 
tains where  he  remained  till  the  ulceration  had  healed.  Need- 
less to  say  he  refused  to  continue  this  "painless"  method  of 
cure,  and  I  lost  my  patient  and  not  a  little  reputation. 

Case. — Male,  aged  fifty-three.  Also  a  private  patient,  and 
in  fair  general  condition,  but  with  old  and  severe  haemorrhoids 
and  partial  prolapse,  and  weakening  of  the  sphincter.  I  was 
first  called  to  see  him  in  the  night,  when  he  was  suffering  from 
strangulation  of  the  entire  mass,  and  a  week  later  I  began  the 
use  of  the  acid.  This  was  followed  very  cautiously  and  with 
abundant  intervals  of  rest  after  each  injection,  and  in  a  very 
short  time  the  relief  was  very  apparent  in  the  diminution  of  the 
size  of  the  protrusion.  There  was  no  pain  at  any  time  during 
the  treatment,  and  only  a  slight  nipping  sensation  for  an  hour 
or  so  after  each  injection.  In  the  end  he  was  entirely  cured, 
all  haemorrhage  and  protrusion  of  the  tumors  having  ceased, 
though  the  anus  was  still  surrounded  by  the  redundant  circle 
of  half  skin  and  half  mucous  membrane  which  remained  from 
the  former  condition  of  prolapse. 

Case. — Clergyman,  aged  forty-eight.  This  case  and  the 
following  one  were  selected  for  treatment  by  injection  for  the 
simple  reason  that  they  were  the  worst  cases  of  long-standing 
and  advanced  hemorrhoidal  disease  which  had  come  to  my 
office  in  months.  This  gentleman  had  been  forced  to  retire 
from  the  active  duties  of  his  profession  ;  was  nervous,  excitable, 
and  dyspeptic ;  suffered  from  palpitation,  loss  of  sexual  power, 
and  pulmonary  disease ;  and  the  tumors  when  prolapsed 
formed  a  mass  fully  as  large  as  a  large  hen's  egg.  The  treat- 
ment lasted  about  four  months.  The  solutions  were  of  varying 
strength,  sometimes  strong  enough  to  cause  sloughing  of  a 
considerable  portion  of  a  tumor,  but  generally  weaker.  When 
a  strong  solution  was  used  and  a  slough  produced  the  injection 

10 


146  DISEASES    OF    THE    RECTUM    AND    ANUS. 

was  not  repeated  for  two  or  three  weeks,  until  the  part  had 
healed  and  the  disturbance  subsided.  The  weaker  solutions 
were  used  much  more  frequently,  the  patient  coming  to  me 
twice  a  week  and  sometimes  receiving  two  or  three  injections  at 
each  visit.  The  treatment  was  not  entirely  painless,  for  when 
a  strong  injection  was  used  there  was  more  or  less  subsequent 
suffering,  and  the  patient  was  willing  to  follow  directions  and 
spend  a  considerable  portion  of  the  day  on  the  lounge  with  a 
book ;  but  he  was  at  no  time  actually  confined  to  the  house, 
nor  was  it  ever  necessary  for  me  to  visit  him  there,  nor  ad- 
minister anything  more  than  an  anodyne  suppository.  At  the 
end  of  four  months  he  was  cured,  and,  I  believe,  as  thoroughly 
cured  as  though  he  had  been  etherized  and  the  tumors  removed 
in  any  other  way.  Six  months  after  the  cessation  of  the  treat- 
ment he  reported  at  my  office  fully  as  well  as  wrhen  the  treat- 
ment was  concluded. 

Case.—  H.  L ,  aged  forty-two.  Sent  by  Dr.  W.  M.  Bill- 
iard. This  man  had  been  a  constant  sufferer  for  twenty-five  years. 
The  tumors  surrounded  the  whole  circumference  of  the  anus, 
were  large  and  pendulous,  prolapsed  easily,  and  bled  freely.  In 
eight  weeks  he  pronounced  himself  cured,  and  there  was  neither 
pain,  bleeding,  nor  protrusion.  The  cure  was  accomplished 
without  a  day's  detention  from  business,  and  with  only  slight 
annoyance  after  one  or  two  of  the  injections,  which  varied  in 
strength  from  one  part  in  six  to  one  in  twenty-five.  At  the 
end  of  six  months  he  also  had  had  no  return  of  his  trouble. 

These  cases  have  been  selected  simply  as  illustrations,  and 
it  would  be  useless  to  multiply  them.  I  have  used  this  method 
of  treatment  now  many  times,  and  except  in  the  third  case  re- 
ported here,  have  never  had  reason  to  regret  using  it,  or  to  be 
dissatisfied  with  its  results,  as  far  as  I  have  been  able  to  follow 
them.  The  unfortunate  result  in  that  case  was  rather  my  fault 
than  the  fault  of  the  treatment,  and  would  not  happen  wrere  the 
solution  properly  selected  ;  but  at  that  time  the  treatment  was 
new  to  me,  and  all  that  I  really  knew  about  it  was  from  the 
reports  of  patients  who  had  been  cured  by  certain  irregular 
practitioners. 

Although  I  should  be  very  slow  to  advocate  any  one  treat- 
ment of  this  affection  to  the  exclusion  of  all  others,  I  now 
generally  adopt  this  by  preference,  and  as  yet  I  have  not  known 
it  to  fail.     Its  advantages  over  all  other  methods,  provided  its 


HEMORRHOIDS.  147 

results  prove  equally  satisfactory,  are  manifest  to  all.  The  pa- 
tient is  not  terrified  at  the  outset  by  the  prospect  of  a  surgical 
operation,  is  not  confined  to  his  bed,  and  is  not  subjected  to  any 
considerable  suffering.  The  cure  goes  on  almost  painlessly  and 
without  his  consciousness. 

There  are  no  objections  to  this  method  which  do  not  apply 
equally  to  others.  I  have  once  seen  considerable  ulceration 
result  from  it,  but  I  have  seen  an  equal  amount  follow  the  ap- 
plication of  the  ligature  ;  and  I  do  not  consider  this  as  a  danger 
greatly  to  be  feared  when  injections  of  proper  strength  are 
introduced  in  the  proper  way.  It  is  applicable  to  all  cases  ;  is 
especially  adapted  to  bad  cases ;  and  may  be  used,  as  in  the 
second  case,  where  a  cutting  operation  is  inadmissible.  It  acts 
by  setting  up  an  amount  of  irritation  within  the  tumor  which 
results  in  an  increase  of  connective  tissue,  a  closure  of  the 
vascular  loops,  and  a  consequent  hardening  and  decrease  in 
the  size  of  the  hemorrhoid.  Except  when  sloughing  occurs,  the 
tumors  are  not,  therefore,  removed,  but  are  rendered  inert  so 
that  they  no  longer  either  bleed  or  come  down  outside  of  the 
bod}'.  In  cases  in  which  the  sphincter  has  become  weakened 
by  distention,  the  injections  will  also  have  a  decided  effect  in 
contracting  the  anal  orifice,  as  do  injections  of  ergot  or  strych- 
nine in  cases  of  prolapse. 

I  must  confess  that  as  my  experience  with  the  method  has 
increased,  the  objections  to  it  which  are  now  generally  made, 
and  to  which  I  at  first  attached  considerable  importance,  have 
gradually  lost  their  force.  These  objections  are  briefly  four- 
pain,  ulceration,  embolus,  and  the  uncertainty  of  the  result. 
The  first  two  are  matters  which  depend  in  great  measure  upon 
the  strength  of  the  solution  employed,  and  are,  therefore,  within 
the  control  of  the  operator.  As  for  embolus  I  can  see  no  more 
reason  why  the  clot  formed  in  this  way  should  become  detached 
and  pass  into  the  general  circulation,  than  should  the  clot 
formed  on  the  proximal  side  of  the  ligature.  In  my  own  prac- 
tice, as  I  have  said,  the  results  have  been  uniformly  satisfactory, 
and  when  ulceration  has  been  produced  I  have  found  it  no 
more  difficult  to  manage  than  that  which  follows  the  detach- 
ment of  the  ligature. 

The  method  requires  some  practice  and  some  skill  in  manip- 
ulation in  getting  a  good  view  of  the  point  to  be  injected  and  in 
making  the  injection  properly.    In  the  first  three  cases  reported, 


us 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


the  solution  employed  was  one  part  of  pure  carbolic  acid  to 
three  of  glycerine  and  three  of  water  ;  in  the  last  the  carbolic 
acid  was  decreased  one-half,  and  this  is  a  better  solution  to  use. 
I  have  experimented  with  solutions  varying  in  strength  from 
five  to  thirty-three  per  cent.,  and  am  much  better  satisfied  with 
the  former  figure  than  the  latter,  which  will  frequently  cause 
sloughing.  The  results  obtained  by  the  weaker  solutions  are  in 
the  end  as  good  as  the  others,  and  the  amount  of  disturbance  is 
I  have  also  used  solutions  of  tincture  of  iron  and  of  ergo- 


less. 


tine,  but  I  prefer  the  carbolic  acid,  the  iron  being  much  more 
painful.  Twice  I  have  had  it  cause  fainting  from  the  immediate 
suffering  it  caused.     The  amount  injected  each  time  should  be 


Fig.  53. — Hypodermic  Syringe  for  Injecting  Haemorrhoids. 

about  five  drops.  The  instrument  used  is  a  hypodermic  syringe 
such  as  is  shown  in  Fig.  53,  with  a  fine,  long  needle,  through 
which  the  solution  will  readily  pass.  When  the  tumor  to  be 
injected  is  prolapsed,  the  needle  may  be  thrust  into  it  without 
difficulty,  and  after  the  injection  is  made  the  tumor  should  be 
gently  replaced.  If  it  be  allowed  to  stay  out  of  the  anus  for  a 
few  moments  it  will  be  seen  to  swell  up  and  become  black  and 
hard  with  venous  blood.  There  is  seldom  any  haemorrhage 
from  the  operation,  but  occasionally  a  few  drops  of  blood  will 
follow  l ho  puncture.  If  the  tumor  is  not  protruded  at  the  time 
of  operation  it  may  be  seized  with  toothed  forceps  (Fig.  54),  and 
drawn  out  and  held  while  the  injection  is  made,  or  a  speculum 


HEMORRHOIDS. 


149 


may  be  used.  The  injection  should  be  landed  as  nearly  as  pos- 
sible in  the  centre  of  the  hemorrhoid,  the  needle  being  entered 
perpendicularly  from  the  apex,  and  not  passed  upward  under 
the  mucous  membrane  in  a  longitudinal  direction.  If  the  acid 
be  placed  simply  under  the  mucous  membrane  the  latter  will 
die  and  an  ulcer  result,  but  if  placed  more  deeply  the  danger 
of  an  ulcer  is  much  decreased.  Used  in  this  way  and  in  the 
strength  last  indicated  the  acid  will  not  be  followed  by  any 
great  amount  of  pain.  Each  injection  should  be  followed  by 
a  day's  rest  in  the  horizontal  position.  No  change  need  be 
made  in  the  ordinary  diet  of  the  patient  provided  the  bowels 
act  regularly  every  day.     Only  one  tumor  should  be  injected  at 


Fig.  54. — Forceps  for  Bringing  Down  Haemorrhoids. 


a  time,  and  I  seldom  repeat  the  injections  of  tener  than  once  a 
week.  It  will  sometimes  be  found  necessary  to  inject  the  same 
tumor  two  or  three  times  when  it  is  a  large  one. 

It  will  be  observed  that  in  the  cases  reported  the  length  of 
time  during  which  the  patient  was  under  treatment  was  in  each 
case,  except  the  second,  between  three  and  four  months.  I  have 
no  doubt  that  this  could  be  much  shortened,  were  it  necessary  ; 
but  where  the  patient  is  at  no  time  confined  to  the  house,  time 
is  of  little  consequence,  and  I  seldom  repeat  the  applications 
of  tener  than  twice  a  week,  preferring  to  see  the  full  effect  of 
each  one  before  giving  a  second.  Still,  were  there  any  reason 
for  haste,  I  should  not  hesitate  to  shorten  this  interval,  and  I 
know  that  in  the  hands  of  the  quacks  the  time  is  considerably 
shortened.  I  believe  also  that  with  them  it  is  the  custom  to 
produce  a  considerable  sloughing  of  each  tumor  by  the  strength 


150  DISEASES    OF    THE    RECTUM    AND    ANUS. 

of  the  injection,  and  several  times  I  have  had  patients  come  to 
me  in  this  condition  after  a  single  injection.  But  no  such  use  of 
the  acid  is  necessary  to  effect  a  cure,  and  sloughing  is  a  result 
which  I  try  very  carefully  to  avoid. 

I  was  sent  for  not  long  since  in  the  middle  of  the  night  to  see 
a  gentleman  suffering  intensely  with  piles.  A  large,  venous,  ex- 
ternal hemorrhoid  had  formed  suddenly  two  days  before,  and 
his  physician  had  injected  into  it  a  few  drops  of  carbolic  acid 
while  it  was  still  tense,  inflamed,  and  exquisitely  tender.  The 
puncture  had  bled  continuously,  drop  by  drop,  ever  since  the 
operation,  and  the  pain  was  exceedingly  severe,  but  there 
seemed  to  have  been  no  other  effect.  I  merely  mention  the  case 
to  say  that  in  this  particular  class  of  cases  the  simple  incision 
is  a  much  better  plan  of  treatment  than  any  injection ;  and, 
generally,  that  the  injections  are  for  internal  and  not  external 
hemorrhoids. 

Treatment  by  Ligature. — This  is  the  method  of  treatment 
which  has  been  brought  to  such  perfection  by  Allingham,  and 
which  usually  passes  by  his  name.  It  consists  in  partially  cut- 
ting through  the  hemorrhoid  at  its  base,  and  tying  the  remain- 
der.   It  is  performed  in  the  following  manner : 

As  in  all  operations  on  the  rectum,  the  bowel  should  be 
thoroughly  cleared  by  a  cathartic  on  the  previous  day  and  by 
an  enema  just  before  operating.  The  patient  may  be  placed 
either  on  the  side  or  in  the  lithotomy  position  ;  personally  I 
prefer  the  latter.  The  sphincter  should  be  carefully  dilated,  as 
already  described,  and  this  is  a  step  of  great  practical  impor- 
tance, as  the  securing  of  complete  paralysis  of  the  muscle  will 
do  more  than  anything  else  to  prevent  pain  and  spasm  after  the 
operation.  In  cases  where  the  tumors  were  large  and  prolapsed 
readily,  I  have  seen  this  step  in  the  operation  omitted  as  un- 
necessary by  good  surgeons  ;  and  I  have  seen  a  week  of  great 
suffering  to  the  patient  follow  the  omission.  So  important  is 
this  step  in  the  operation,  for  the  relief  of  pain,  that  in  some 
cases  in  which  the  tumors  were  so  extensive  and  the  sphincter 
so  dilated  that  they  could  easily  be  removed  without  it,  I  have 
first  cut  off  the  haemorrhoids  and  then  stretched  the  sphincter. 
It  is  rather  a  reversal  of  the  regular  order,  but  it  illustrates  the 
fact  that  stretching  the  muscle  should  not  be  omitted.  If  the 
muscle  is  forcibly  and  suddenly  torn  apart  by  the  operator,  a 
fissure  may  result,  and  may  require  a  subsequent  operation  for 


H^EMORKHOIDS. 


151 


its  cure  after  recovery  from  the  original  operation.  The  tumors 
being  thus  brought  into  full  view  by  the  introduction  of  a  spec- 
ulum, one  is  seized  and  drawn  down  with  a  toothed  forceps. 
The  selection  of  a  good  forceps  for  this  purpose  is  a  matter  of 
considerable  importance.  In  my  own  operations  I  use  those 
shown  in  Fig.  55,  though  the  instrument  sold  under  Luer's  name 
(Fig.  56)  is  an  exceedingly  good  one.  The  hold  is  firm  in  either 
case,  and  the  handle  sufficiently  long  for  the  hand  of  the  assist- 
ant to  be  out  of  the  way  of  the  operator  in  the  subsequent  steps. 


Fig.  55. 

Having  secured  a  good  firm  hold  on  the  tumor,  the  surgeon 
transfers  the  forceps  to  the  left  hand,  and  with  a  strong  and 
long  pair  of  straight  scissors  cuts  the  hemorrhoid  away  from 
its  attachments  for  a  certain  distance,  beginning  from  below 
and  cutting  upward.  In  this  way  the  mass  is  entirely  cut  off 
except  at  its  upper  end,  where  the  artery  or  arteries  which  feed 
it  enter  it  from  above.  It  is  to  prevent  haemorrhage  from  these 
vessels  that  the  ligature  is  applied  instead  of  completely  cutting 


Fig.  56. — Luer's  Haemorrhoidal  Forceps. 

off  the  mass  ;  and  this  is  done  by  the  operator  after  transferring 
the  forceps  to  the  assistant.  The  line  of  incision  should  com- 
mence at  the  j  unction  of  the  skin  and  mucous  membrane,  shown 
in  Fig.  52. 

The  ligature  should  be  of  stout  hemp,  something  stouter 
than  ordinary  ligature  silk  being  necessary.  The  string  should 
be  tied  very  tightly,  and  after  it  is  secured  the  pile  may  be  cut 
off  to  remove  as  much  as  possible  of  the  dead  tissue  from  the 
rectum.     Each  hemorrhoid  is  thus  treated  in  succession,  and 


152  DISEASES    OF   THE    RECTUM   AND    ANUS. 

after  all  are  removed,  a  suppository  of  opium  is  introduced, 
and  a  T-bandage  tightly  applied  over  a  compress  of  lint  and  a 
napkin. 

The  after-treatment  is  a  matter  of  a  good  deal  of  importance. 
It  is  not  well  to  allow  the  bowels  to  be  confined  for  more  than 
two  or  three  days,  and  the  first  passage  should  be  assisted  by  a 
laxative.  Much  less  pain  will  be  caused  by  a  soft  passage  on 
the  third  day  after  the  operation  than  will  result  from  confining 
the  bowels  for  ten  days  or  a  fortnight,  as  is  often  done.  Under 
the  latter  circumstances  the  suffering  caused  by  the  first  pas- 
sage is  often  atrocious,  and  will  not  infrequently  so  tear  the 
mucous  membrane  as  to  produce  a  fissure.  It  is  not  a  good 
plan  to  try  and  introduce  suppositories  after  the  operation,  and 
should  morphine  be  necessary  it  is  better  given  by  the  mouth  or 
hypodermically. 

The  ligatures  will  generally  come  away  about  the  end  of 
the  first  week,  and  the  patient  should  be  kept  in  bed  or  on 
the  lounge  for  a  week  longer.  This  in  an  active  person  will 
sometimes  be  difficult  to  manage  ;  but  no  other  course  should 
be  sanctioned  by  the  surgeon,  for  the  reason  that  when  the 
ligature  comes  away  an  ulcerated  spot  is  left  ;  and  under  cer- 
tain circumstances,  the  most  effective  of  which  is  active  exer- 
cise, these  little  wounds  may  grow  larger  instead  of  smaller. 
In  this  way  a  case  of  internal  haemorrhoids  may  be  turned  by  an 
operation  into  one  of  ulceration  of  the  rectum,  and  the  change 
is  not  to  the  advantage  of  the  patient.  One  such  case  I  have 
had  in  my  own  practice,  in  a  debilitated  patient  in  poor  general 
health  ;  and  a  long  course  of  careful  treatment  was  necessary  to 
effect  an  ultimate  cure. 

Nothing  has  been  said  regarding  primary  or  secondary 
haemorrhage,  for  the  reason  that  it  is  not  a  complication  to  be 
looked  for.  The  diet  for  the  first  few  days  should  be  chiefly 
fluid. 

This  operation,  thanks  to  Mr.  Allingham,  is  now  so  well  and 
so  favorably  known,  that  but  little  need  be  said  in  addition.  It 
is  as  safe  as  any  operation  in  surgery,  and  by  it  the  surgeon 
may  promise  his  patient  an  absolute  and  permanent  cure  of  his 
troubles  in  every  case.  This  is  saying  a  great  deal,  but  not  too 
much.  It  has  been  followed  by  fatal  results— but  so  has  every 
other  minor  surgical  operation;  and  the  chance  of  such  a  ter- 
mination is  so  slight  that  it  need  not  enter  into  the  calculation 


HAEMORRHOIDS.  153 

of  the  operator.  So  much  may  be  said  in  its  favor,  but  there 
are  certain  objections  to  it  which  it  is  well  to  bear  in  mind,  es- 
pecially when  recommending  it  to  the  patient  and  assuring  him 
that  it  is  merely  a  trifling  affair.  In  a  case  operated  upon  in 
consultation  with  Dr.  C.  H.  Avery,  of  New  York,  we  came  very 
near  losing  our  patient  (a  strong  man  in  good  condition  for 
operation)  from  what  bid  fair  to  be  pyaemia.  But  excluding 
this  complication,  which  may  follow  any  wound,  the  operation 
itself  is  not  a  light  matter,  and  the  surgeon  when  he  undertakes 
it  can  never  be  exactly  sure  of  how  much  suffering  his  patient 
will  have  to  endure  before  a  cure  is  accomplished.  There  may 
be,  and  often  is,  severe  haemorrhage  at  the  time  of  the  operation, 
which,  though  not  dangerous,  will  require  a  moderate  stuffing 
of  the  rectum  with  lint  for  its  control ;  and  if  this  is  resorted  to 
an  additional  element  of  trouble  will  be  found  when  its  removal 
becomes  necessary.  Again,  the  constitutional  disturbance  is 
often  severe.  There  will  often  be  considerable  nervous  excite- 
ment, a  frequent  pulse,  loss  of  sleep,  pain  sufficient  to  demand 
the  use  of  morphine  for  days,  obstinate  retention  of  urine  which 
may  render  catheterism  necessary  for  a  fortnight,  swelling  of 
the  parts  around  the  anus,  and  finally  undue  contraction  after 
cicatrization  which  will  entail  the  use  of  the  bougie.  That  this 
picture  is  not  overdrawn  the  experience  of  most  men  who  have 
had  a  large  number  of  these  cases  will,  I  think,  prove. 

Operation  with  the  Clamp  and  Cautery. — This  is  generally 
known  as  Smith's  operation,  because  he  has  advocated  it  so 
forcibly  and  practised  it  with  such  good  results.  He  claims  no 
credit  for  introducing  it,  however,  this  being  due  to  Mr.  Cusack, 
of  Dublin,  and  his  own  originality  has  been  chiefly  spent  in  im- 
proving the  clamp,  which  is  shown  below. 

The  operation  consists,  according  to  Dr.  Smith's  most  re- 
cent description,  in  drawing  down  the  tumor,  embracing  its  base 
in  the  clamp,  and  removing  it  with  the  serrated  and  cutting 
cautery  knives  shown  in  the  cut.     (Fig.  57.) 

It  is  important  to  isolate  the  tumors  well,  so  as  to  compress 
them  easily  and  completely,  and  in  some  cases  where  the 
hemorrhoid  runs,  as  it  were,  abruptly  into  the  hypertrophied 
skin,  Smith  recommends  the  previous  making  of  a  slight  groove 
with  the  scissors,  so  that  the  compression  of  the  neck  of  tumor 
may  be  the  more  effectual.  The  base  should  not  be  divided  too 
close  to  the  clamp  lest  there  be  not  enough  tissue  left  for  the 


154 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


proper  application  of  the  hot  iron.  The  latter  is  to  be  applied 
very  thoroughly  and  slowly  at  a  black  heat ;  and  the  blades  of 
the  clamp  may  then  be  gradually  released  by  the  screw.  Should 
any  vessel  not  thoroughly  cauterized  bleed  when  the  pressure  is 
taken  off,  the  clamp  must  be  again  screwed  up  and  the  cautery 
again  applied.     It  may  be  necessary  to  do  this  several  times. 

The  advantages  claimed  for  this  operation  by  Smith  over 
that  of  Allingham,  with  which  it  comes  most  naturally  into  com- 
parison, are  greater  safety  to  life,  greater  freedom  from  suffer- 


Fig.  57. — Smith's  Clamp  and  Serrated  and  Cutting  Cauteries. 

ing,  and  a  more  rapid  recovery,  with  less  danger  of  pyeemia,  of 
ulceration,  and  of  embolus,  and  less  constitutional  disturbance 
after  the  operation.  With  regard  to  the  painlessness  of  the 
operation,  a  point  on  which  I  have  asked  further  information 
from  Mr.  Smith,  he  very  kindly  wrote  me  as  follows :  "I  mean 
by  that  to  state  that  by  very  great  care  in  selected  cases,  and 
by  the  use  of  the  clamp  well  shielded  by  the  ivory,  and  when 
no  skin  is  to  be  removed,  the  operation,  as  I  have  often  verified, 
is  attended  by  very  little  pain.  As  a  rule,  in  severe  cases  I  use 
an  anassthetic,  and  I  never  dilate  the  sphincter,  but  sometimes 
divide  it." 


HAEMORRHOIDS.  155 

The  reader  is,  therefore,  at  liberty  to  choose  between  these 
two  procedures.  My  own  experience  has  been  almost  entirely, 
confined  to  the  former  operation  where  I  desired  to  remove  only 
a  moderately  large  hemorrhoidal  protuberance,  and  I  have  re- 
served Mr.  Smith's  method  for  cases  of  extensive  disease  where 
much  tissue  was  to  be  removed,  whether  it  were  a  case  of  severe 
haemorrhoids  with  prolapsus,  such  as  is  shown  in  Plate  II.,  Fig. 
3,  or  of  prolapsus  alone.  The  array  of  unfortunate  cases,  espe- 
cially of  haemorrhage,  given  by  Mr.  Smith,  in  which  he  has  per- 
formed the  operation  of  Allingham,  confirms  very  strongly  what 
has  already  been  said  against  that  operation  ;  but  I  am  unable 
to  see  why  one  should  be  any  more  fatal  than  the  other,  and 
the  operation  with  the  ligature  may  also  be  performed  with  lit- 
tle pain  and  without  an  anaesthetic  in  certain  selected  cases.  I 
have  done  it  several  times  in  my  office,  tying  off  only  one  tumor 
at  a  time,  however,  where  the  sphincter  was  relaxed,  and  the 
tumors  well  separated  from  each  other.  Since  adopting  the 
treatment  by  injections  I  have  had  very  little  use  for  either 
operation,  except  in  cases  of  prolapsus,  and  in  them  I  decidedly 
prefer  the  clamp  and  cautery. 

With  the  means  already  enumerated  every  case  of  internal 
haemorrhoids  may  be  cured  where  a  cure  is  desirable,  or  relieved 
when  radical  cure  is  out  of  the  question,  and  I  shall  not,  there- 
fore, take  the  space  necessary  to  describe  the  various  others 
which  either  have  been  or  are  at  present  in  favor,  such  as 
simple  dilatation  of  the  sphincters,  crushing,  the  galvano-cautery 
wire,  plunging  the  actual  cautery  into  the  substance  of  the 
haemorrhoid,  and  cauterizing  the  skin  of  the  anus  in  radiating 
lines  to  cause  contraction. 

It  will  sometimes  be  found  that  several  of  the  methods  de- 
scribed may  be  used  with  advantage  on  the  same  case.  Thus, 
for  example,  a  patient  may  present  himself  with  one  haemor- 
rhoid which  seems  particularly  adapted  for  the  ligature,  with 
another  strawberry-like  growth  which  can  be  eradicated  with  a 
single  application  of  nitric  acid,  and  with  others  which  may  be 
cured  by  injections.  All  three  methods  may  be  used  without 
confining  the  patient  to  his  room  or  causing  any  great  amount 
of  suffering,  as  I  have  often  proved,  and  by  a  combination  of 
them  all  a  radical  cure  may  be  reached  more  quickly  and  pain- 
lessly than  by  any  one  method  singly. 


CHAPTER  VII. 

PROLAPSE. 

Four  Varieties. — First  Variety:  Prolapse  of  the  Mucous  Membrane  Alone. — Second 
Variety:  Prolapse  of  all  the  Coats  of  the  Rectum. — Third  Variety:  Prolapse  of 
the  Upper  Part  of  the  Rectum  into  the  Lower,  or  Invagination. — Fourth  Variety  : 
Invagination  in  the  Continuity  of  the  Bowel. — Prolapse  of  the  Mucous  Membrane 
Alone. — Causes. — Symptoms. — Treatment:  Palliative  and  Curative. — Prolapse 
with  Haemorrhoids. — Treatment  by  Injections. — Cauterization. — Description  of 
Operation. — Smith's  Clamp. — Dupuytren's  Operation. — Prolapse  of  the  Second 
Degree.  — Pathological  Changes.  —  Presence  of  Peritoneum.  — Strangulation. — 
Ad  visibility  of  Reducing  Inflamed  or  Gangrenous  Prolapse. — Excision  of  Prolapse 
after  the  Formation  of  a  Slough. — Third  and  Fourth  Varieties. — Differences  be- 
tween Third  and  Fourth. — Degrees  of  Invagination. — Anatomical  Appearances. — 
Pathology. — Relative  Frequency. — Symptoms.— Physical  Signs. — Acute  and 
Chronic  Forms. — Diagnosis. — Differential  Diagnosis  from  Volvulus ;  from  Strict- 
ure ;  from  Internal  Hernia  ;  from  Obstruction  by  Pressure  from  without  the 
Bowel ;  from  Foreign  Bodies  ;  from  Peritonitis  with  Perforation. — Treatment. — 
Replacement  by  Manipulation. — Treatment  by  Injections. — Treatment  by  Punc- 
ture.— Laparotomy. — Description  of  Operation. 

Of  prolapse  of  the  rectum  and  invagination  there  are  four  dis- 
tinct varieties. 

1.  Prolapse  of  the  Mucous  Membrane  Alone. — This,  which 
is  sometimes  spoken  of  as  "partial"  prolapse,  because  only  a 
part  of  the  wall  of  the  rectum  is  involved  in  the  descent,  is  well 
represented  in  Fig.  58. 

2.  Prolapse  of  all  the  Coats  of  the  Rectum,  including,  when 
the  Disease  is  of  sufficient  Extent,  the  Peritoneum.    (Fig.  59.) 

3.  Prolapse  of  the  Upper  Part  of  the  Rectum  into  the  Lower, 
or  Invagination.     (Fig.  60.) 

4.  Invagination  in  the  Continuity  of  the  Intestine. — The 
same  condition  as  the  third  variety,  only  occurring  in  a  part  of 
the  bowel  further  away  from  the  rectum. 

The  first  form  is  a  mere  everting  of  the  mucous  membrane 
of  the  lowest  portion  of  the  rectum,  rendered  possible  by  the 
laxity  of  the  submucous  connective  tissue.  It  is  seen  as  an  ac- 
companiment of  old  cases  of  haemorrhoids,  and  its  mechanism 


PROLAPSE.  157 

may  be  studied  at  airf  time  upon  the  horse,  in  which  it  occurs 
naturally  at  the  close  of  each  act  of  defecation. 

The  second  variety  is  an  exaggeration  of  the  first,  in  which, 
after  the  submucous  connective  tissue  has  yielded  to  its  utmost, 


Pig.  58.— First  Variety  of  Prolapse.    (Molliere.) 

the  whole  thickness  of  the  rectum  begins  to  descend,  and  finally 
protrudes.  It  follows,  of  necessity,  that  after  this  protrusion 
has  reached  a  certain  length,  the  peritoneal  coat  must  also  de- 


Fig.  59. — Second  Variety  of  Prolapse.   (Molliere.) 


scend  outside  of  the  body,  and  this  condition  is  shown  at  a 
glance  by  reference  to  the  plate. 

In  both  of  these  forms  the  protrusion  begins  first  at  the  part 
of  the  rectum  nearest  the  anus.    In  the  third  form,  the  part  of 


158  DISEASES    OF   THE   EECTUM    AND    ANUS. 

the  rectum  higher  up  is  passed  through  that  nearer  the  anus, 
and  what  is  known  as  an  invagination  occurs.  This  condition 
must,  of  necessity,  cause  a  sulcus  or  groove  to  exist  between 
the  containing  and  the  contained  portion ;  and  at  the  bottom  of 
this  sulcus  the  mucous  membrane  of  one  is  directly  continuous 
with  that  of  the  other.  The  depth  of  this  sulcus  must  depend 
upon  the  point  at  which  the  invagination  occurs,  but  in  the 
variety  under  consideration,  its  bottom  can  generally  be  felt  by 
introducing  the  finger  by  the  side  of  the  protruding  portion. 

In  the  fourth  variety  this  sulcus  also  exists,  but  its  bottom 
cannot  be  felt,  the  point  at  which  the  invagination  has  occurred 
being  in  the  continuity  of  the  bowel,  too  far  away  from  the 
anus.  In  the  first  three  forms  of  the  disease  there  is  always  a 
protrusion  of  a  portion  of  the  bowel  through  the  anus  ;  in  the 
fourth,  there  may  be  no  such  protrusion,  the  lower  end  of  the 
invaginated  bowel  being  still  within  the  rectum,  or,  perhaps, 
too  far  up  the  canal  to  be  seen  or  felt. 


FlG.  60.— Third  Form  of  Prolapse.    (Bryant.) 

Having  thus  briefly  defined  the  different  varieties  of  prolapse 
and  invagination,  we  shall  consider  each  one  in  detail. 

Prolapse  of  the  Mucous  Membrane  Alone. — This  is,  per- 
haps, the  most  common  of  all  the  varieties  of  the  disease  when 
we  take  into  consideration  its  frequent  coexistence  with  haemor- 
rhoids. It  is  found  in  children  most  often  between  the  years  of 
two  and  four,  and  in  adults  it  is  more  frequent  in  women  than 
in  men.  Its  causes  are  various.  Among  them  may  be  enumer- 
ated the  following  :  a.  Those  which  tend  mechanically  to  draw 
down  the  mucous  membrane,  such  as  haemorrhoids,  polypus, 
vegetations,  and  tumors,  b.  Those  which  tend  to  weaken  or  to 
destroy  the  action  of  the  sphincters,  such  as  ulcerations  or  in- 
cisions, c.  Those  which  cause  muscular  spasm,  such  as  fissures, 
worms,  dysentery,  phymosis,  cystitis,  calculus,  stricture  of  the 
urethra,  and  enlarged  prostate,  d.  Those  which  produce  per- 
manent dilatation  and  weakening  of  the  sphincters,  such  as 


PROLAPSE.  159 

spinal  paralysis,  traumatism,  chronic  constipation,  and  sodomy. 
In  this  last  connection,  Molliere  '  details  a  very  interesting  case 
from  his  personal  observation  in  a  woman  suffering  from  vesico- 
vaginal fistula.  Her  husband,  a  brutish  peasant,  not  daring  to 
practise  coitus  in  the  ulcerated  vagina  of  his  wife,  subjected  her 
to  unnatural  intercourse  daily  for  more  than  a  year,  with  the 
result  of  producing  a  relaxation  of  the  sphincter  which  showed 
itself  by  prolapse  to  an  enormous  extent,  and  by  incontinence. 
To  this  lack  of  tonicity  of  the  sphincters  may  be  attributed  the 
frequent  occurrence  of  prolapse  in  feeble  and  badly  nourished 
children,  e.  Those  which  produce  oedema  and  swelling  of  the 
pelvic  tissues,  such  as  pregnancy,  parturition,  faecal  accumula- 
tions, and  hepatic  lesions. .  In  this  connection  also,  Molliere  a 
details  an  instructive  experiment  which  may  easily  be  repeated 
on  the  cadaver.  He  says :  "On  the  cadaver  of  a  young  girl,  I 
introduced  under  the  mucous  membrane  of  the  anus  a  blow- 
pipe, and  fastened  it  with  a  ligature.  By  practising  insufflation 
the  air  instantly  spread  in  the  submucous  rectal  tissue,  and 
the  mucous  membrane  escaped  from  the  anus.  I  repeated  the 
same  manoeuvre  at  another  point  of  the  circumference  of  the 
anus,  with  the  same  result.  By  dissection  I  was  able  to  assure 
myself  that  only  the  mucous  membrane  had  been  raised  up.  It 
was  then  sufficient  in  this  case  to  cause  tumefaction  of  the  sub- 
mucous tissue  to  produce  prolapse  ;  and,  moreover,  in  this 
subject,  the  anus  was  still  firmly  closed."  f.  To  these  causes, 
it  may  be  proper  to  add  one  anatomical  one — the  undeveloped 
sacrum  in  children,  which,  by  its  straightness,  leaves  the  rectum 
comparatively  unsupported. 

Symptoms. — This  first  form  of  prolapse  always  comes  on 
gradually  and  never  suddenly.  It  may  be  partial  or  complete 
as  regards  the  circumference  of  the  anus,  being  in  some  cases  of 
hsemorrhoids  confined  to  one  side  of  the  aperture,  and  in  others 
involving  the  whole  circumference.  It  presents  itself  as  a  scar- 
let or  livid  mass  (depending  upon  the  state  of  contraction  of  the 
sphincter)  projecting  from  the  anus,  covered  with  the  natural 
secretion  of  the  bowel,  directty  continuous  with  the  skin  on 
one  side  and  with  the  mucous  membrane  on  the  other,  and  ar- 
ranged in  folds  which  radiate  from  the  central  aperture  toward 
the  circumference.     It  is  at  first  spontaneously  reducible,  or  at 

1  Op.  cit,  p  202.  i  Op.  cifc.,  p.  199. 


160  DISEASES    OF   THE    RECTUM    AND    ANUS. 

least  easily  replaced  by  a  slight  pressure,  and  remains  reduced 
till  the  next  act  of  defecation  ;  but  as  the  amount  of  prolapsed 
membrane  increases,  the  difficulty  in  reduction  becomes  greater. 
At  first  also  there  is  no  pain,  but  after  a  time  the  act  of  defeca- 
tion comes  to  be  greatly  dreaded  by  the  patient,  and  the  suffer- 
ing continues  till  the  tissue  is  replaced. 

Treatment. — The  first  step  in  the  treatment  of  prolapse  of 
the  rectum  to  which  the  surgeon  will  be  called  to  attend  will 
generally  be  to  effect  the  reduction  of  the  mass  ;  after  this  has 
been  accomplished  the  treatment  may  be  either  palliative  or 
curative.  In  children  a  prolapse  may  generally  be  reduced  by 
laying  the  patient  across  the  lap  on  its  face  and  making  gentle 
pressure  on  the  protruded  bowel  with  the  fingers  which  have 
been  well  oiled,  or  with  a  soft  greased  rag.  If  this  cannot  be 
accomplished  by  a  gentle  taxis,  and  without  bruising  the  parts, 
the  child  should  at  once  be  etherized  and  a  curative  procedure 
adopted.  It  is  scarcely  worth  while  in  a  child  to  stop  to  try  the 
various  methods  of  reduction  which  have  been  recommended 
where  the  taxis  has  failed,  before  resorting  to  this  step. 

In  an  adult,  however,  ether  and  operative  interference  may 
both  be  declined,  and  the  surgeon  may  have  to  tax  his  brain  to 
accomplish  the  reduction  without  the  aid  of  an  anaesthetic.  In 
such  a  case,  after  gentle  taxis  has  been  tried  with  the  patient  in 
the  knee-elbow  position,  and  failed,  cold  should  be  applied 
while  the  patient  remains  on  the  face  in  bed  with  a  pillow  under 
the  pelvis  ;  and  this  maybe  alternated  with  warm  poultices  and 
with  plentiful  applications  of  an  ointment  composed  of  equal 
parts  of  ext.  of  belladonna  and  ext.  of  opium.  By  these  means, 
the  most  effectual  of  which  is  position,  reduction  maj^  almost 
always  be  accomplished.  When  by  the  action  of  the  sphincter 
the  prolapse  has  become  gorged  with  blood  and  cedematous,  the 
surgeon  is  often  tempted  to  resort  to  leeches.  They  will  gener- 
ally give  relief,  and  may  greatly  facilitate  reduction,  but  they 
are  not  free  from  the  danger  of  a  concealed  haemorrhage  within 
the  rectum  after  the  prolapse  has  been  replaced. 

The  palliative  treatment  is  directed  entirely  toward  dimin- 
ishing the  frequency  and  the  amount  of  the  prolapse,  and  in 
children  a  cure  may  sometimes  be  obtained  by  these  means 
without  resorting  to  surgical  interference.  The  act  of  defeca- 
tion is  first  to  be  regulated,  and  should  be  performed  with  the 
patient  in  the   recumbent   posture   in  bed,  or  while   standing. 


PROLAPSE.  161 

One  buttock  may  also  be  drawn  aside  so  as  to  tighten  the  anal 
orifice  with  advantage  ;  and  any  source  of  irritation  which  pro- 
duces frequent  defecation  and  straining  in  the  act  must  be  re- 
moved. After  the  action  of  the  bowels,  if  the  prolapse  has  oc- 
curred, the  bowel  should  be  thoroughly  washed  with  cold  water 
and  a  solution  of  alum  (3j.  to  fviij.)  before  it  is  returned. 
Another  favorite  wash  is  composed  of  the  tincture  of  iron, 
twenty  to  thirty  drops  to  four  ounces  of  water.  The  patient 
should  then  be  confined  to  the  bed  for  some  time,  and  pressure 
should  be  applied  over  the  anus  by  a  pad  kept  in  place  by  a 
T-bandage  in  the  adult,-  or  by  a  broad  strip  of  adhesive  plaster 
in  children,  applied  so  as  to  draw  the  buttocks  into  close  ap- 
position. A  rectal  supporter  may  also  be  worn  when  the  patient 
is  up  and  about,  and  perhaps  the  best  of  these  is  the  one  made 
by  Mathieu,  and  represented  in  Fig.  61. 


Fig.  61.— Rectal  Supporter. 

After  the  bowel  has  ceased  to  come  down  with  the  act  of 
defecation,  an  astringent  injection  may  be  given  every  night 
with  advantage  and  allowed  to  remain  in  all  night.  The  gen- 
eral health  should  be  carefully  attended  to  ;  tonics  should  be 
administered  where  they  seem  to  be  indicated ;  and  if  well 
borne,  cod-liver  oil  may  be  used  to  fulfil  the  double  indication 
of  tonic  and  laxative.  In  children  these  measures  may,  as  has 
been  said,  be  curative,  and  in  fact  the  disease  often  ceases  spon- 
taneously at  about  the  time  of  puberty  ;  but  in  adults  they  are 
not  at  all  likely  to  be  so,  and  more  radical  measures  will  gener- 
ally be  necessary.  Of  these  there  are  several  which  are  effect- 
ual, and  each  of  them  has  its  supporters  and  advocates. 

In  cases  of  prolapse  attending  old  internal  haemorrhoids,  the 
operation  for  the  removal  of  the  latter  by  the  ligature  may  easily 
11 


162  DISEASES    OF    THE    RECTUM    AND    ANUS. 

be  extended  so  as  to  cure  at  the  same  time  the  former  condition. 
And  here  a  little  careful  discrimination  may  be  necessary  to 
distinguish  between  piles  and  prolapsed  mucous  membrane. 
The  piles  are  smooth,  hard,  and  shiny  tumors  ;  the  prolapse  is 
soft  and  velvety  to  the  feel,  and  generally  surrounds  the  whole 
margin  of  the  anus  without  being  divided  into  distinct  tumors. 
In  such  a  case  the  proper  course  to  pursue  is  to  divide  the  pro- 
lapse into  several  sections  with  the  scissors,  and  tie  off  each  one 
exactly  as  though  it  were  an  internal  hemorrhoid.  I  have  sev- 
eral times  performed  this  operation  with  the  happiest  results, 
both  as  to  curing  the  piles  and  the  prolapse  ;  but  caution  must 
be  exercised  as  to  the  amount  of  tissue  removed,  lest  too  great  a 
degree  of  cicatricial  contraction  result. 

Since  beginning  the  use  of  injections  in  the  treatment  of 
hemorrhoids,  I  have  also  in  some  cases  effected  a  cure  of  this 
form  of  prolapse  by  the  use  of  carbolic  acid  in  the  same  way  as 
for  piles.  The  idea  of  using  carbolic  acid  for  this  purpose  is,  I 
believe,  my  own,  and  came  naturally  from  my  trials  of  the 
remedy  in  haemorrhoids ;  but  both  strychnine  and  ergot  have 
been  used  for  the  same  purpose  for  some  time. 

At  a  meeting  of  the  Therapeutical  Society,  December,  1879, 
reported  in  the  Gaz.  Hebdom. ,  January  2,  1880,  Dr.  Ferrand  re- 
lated the  case  of  a  lady  who  had  suffered  three  years  from  pro- 
lapse, the  tumor  being  nearly  the  size  of  the  fist,  and  descending 
even  when  she  walked  across  the  room,  and  causing  great  suf- 
fering. One  gramme  and  twenty  centigrammes  of  a  solution, 
composed  of  glycerin  and  water  aa  fifteen  parts,  and  alkaline 
l^drated  extract  of  ergot  two  parts,  was  injected  into  the 
ischio-rectal  fossa  beside  the  prolapse.  Considerable  benefit 
resulted,  and  three  other  injections  were  practised  at  intervals 
of  twenty  days,  ten  days,  and  a  month,  with  the  result  of  ef- 
fecting a  cure.  The  patient  was  seen  after  an  interval  of  six 
months,  and  it  was  found  that  the  prolapse  was  not  reproduced 
even  by  such  exertion  as  going  up  several  flights  of  stairs. 

Vidal1  also  has  recorded  three  successful  cases  of  cure  with 
ergotine.  The  first  was  that  of  a  man,  aged  thirty-nine,  who 
had  suffered  for  eight  years.  After  five  injections  of  fifteen 
drops  of  a  solution  of  ergotine,  at  intervals  of  two  days,  the 
mucous  membrane  scarcely  protruded  at  all.    After  the  eleventh 

1  Paris  Medical,  Auguat  28,  1879. 


PROLAPSE.  163 

injection  it  only  came  down  during  defecation  and  returned 
spontaneously.  The  whole  number  of  injections  was  twenty- 
two,  and  the  man  remained  perfectly  well  four  years  after. 
The  second  patient,  a  female,  aged  sixty-four,  was  cured  after 
twenty-four  days'  treatment,  and  remained  well  two  years  and 
a  half  after.  The  third  patient,  a  female,  aged  fort}r-five,  was 
cured  in  fifteen  days  by  six  injections  of  twenty  or  twenty-five 
drops  each.  The  solution  used  consisted  of  fifteen  grains  of 
Bonjean's  ergo  tine  dissolved  in  seventy-five  minims  of  cherry- 
laurel  water.  The  injections  were  made  at  the  distance  of  one- 
fifth  of  an  inch  from  the  anus.  Acute  pain  always  followed, 
and  contraction  of  the  sphincter  lasting  several  hours.  Several 
times  an  injection  of  twenty -five  drops  of  the  solution  caused 
spasm  of  the  neck  of  the  bladder  and  retention  of  urine.  In 
no  case  did  the  injections  produce  any  local  inflammation  or 
abscess.  Dr.  Vidal  has  more  recently  expressed  himself  as 
preferring  Yvon's  solution  of  ergot  to  Bonjean's  ergotine,  as 
causing  less  pain.1 

The  danger  to  be  avoided  in  this  method  of  treatment  is  the 
use  of  too  irritating  solutions,  or  solutions  in  too  great  quantity 
which  shall  excite  a  suppurative  action  and  produce  constitu- 
tional poisonous  effects. 

Cauterization. — In  children  in  whom  milder  measures  have 
failed,  a  very  effectual  means  of  cure  is  the  application  of  fum- 
ing nitric  acid  to  the  mucous  membrane  of  the  prolapsed  part. 
The  bowel  should  first  be  carefully  wiped  off  with  a  towel  or 
sponge,  and  the  acid  then  applied  by  means  of  a  small  stick  all 
over  the  mucous  membrane,  but  not  at  all  to  the  skin  adjacent. 
After  such  an  application  the  bowel  should  be  replaced,  a  pad 
of  lint  firmly  applied  over  the  anus  by  means  of  broad  strips  of 
adhesive  plaster,  and  the  bowels  confined  by  means  of  opium. 
Allingham  speaks  of  stuffing  the  rectum  with  wool  in  addition, 
but  I  have  always  found  the  pad  and  straps  sufficient  when 
thoroughly  applied,  and  the  child  kept  on  its  bed.  After  three 
or  four  days  the  straps  may  be  removed,  and  the  bowels  moved 
with  castor-oil.  In  a  large  proportion  of  cases  the  cure  will  be 
found  complete,  though,  in  a  few  cases,  I  have  seen  a  return  of 
the  disease  after  a  few  months.  In  any  case,  however,  the 
benefit  will  be  found  to  be  very  great,  and  should  the  disease 

1  Gaz.  Hebdom.,  January  2,  1880. 


164  DISEASES    OF    THE    RECTUM    AND    ANUS. 

return,  a  very  careful  search  should  be  instituted  for  some  ex- 
isting source  of  irritation,  such  as  polypus,  phymosis,  or  cal- 
culus. In  case  of  a  recurrence,  a  second  application  will  be 
effectual  in  causing  a  cure. 

This  treatment,  though  successful  in  children,  is  by  no 
means  so  in  adults.  Allingham  calls  attention  to  the  occurrence 
of  deep  sloughs  in  old  persons  with  debilitated  constitutions  ; 
and,  as  a  result  of  such  a  slough,  he  has  seen  an  almost  fatal 
haemorrhage.  Stricture  of  the  rectum  may,  without  doubt,  be 
caused  by  too  free  use  of  this  remedy,  but  since  it  follows  its 
abuse  and  not  its  proper  use  in  appropriately  selected  cases,  it 
can  hardly  be  considered  an  objection. 

Linear  Cauterization. — In  adults  this  is  undoubtedly  the 
best  means  at  our  command  for  dealing  with  this  affection,  and 
the  best  means  of  applying  it  is  that  recommended  by  Van 
Buren,  with  Paquelin's  cautery. 

The  patient  is  at  first  etherized  and  placed  in  Sims'  position. 
Van  Buren  reduces  the  prolapse,  and  applies  the  iron  with  the 
aid  of  a  speculum.  Allingham  first  applies  the  iron  and  then 
reduces  the  prolapse.  In  either  case  from  three  to  six  vertical 
stripes  should  be  made  upon  the  mucous  membrane,  with  the 
iron  heated  to  a  dull  red-heat.  The  cauterization  should  begin 
about  three  inches  up  the  rectum,  and  end  at  the  junction  of 
the  skin  and  mucous  membrane.  They  should  also  be  deeper 
at  the  end,  where  there  is  no  danger,  than  at  the  beginning, 
where  the  bowel  may  be  perforated.  Van  Buren  recommends 
that  the  iron  be  bent  at  a  right  angle  a  short  distance  from  the 
end,  so  that  it  may  be  the  more  thoroughly  applied  to  the 
concavity  of  the  rectum,  and  that,  in  mild  cases,  a  small  iron 
should  be  used,  "  no  thicker  than  an  ordinary  probe."  (Fig.  62.) 
Allingham,  in  bad  cases,  burns  through  the  sphincter  muscle  at 
two  opposite  points,  after  reducing  the  bowel,  and  inserts  a 
small  pledget  of  oiled  wool.  By  this  burning  through  the 
sphincter,  the  patulous  condition  of  the  anus  is  overcome.  The 
result  of  the  operation  is  to  decrease  the  circumference  of  the 
anal  orifice,  and  in  this  way  to  effect  a  cure.  The  patient 
should  be  confined  absolutely  to  bed  till  the  wounds  are  entirely 
healed,  so  that  a  recurrence  of  the  descent  may  be  effectually 
avoided. 

For  some  time  after  the  healing,  and  after  the  patient  is 
allowed  to  be  up  and  about,  in  fact,  until  the  full  effect  of  the 


PEOLAPSE. 


165 


operation  has  been  obtained,  a  bed-pan  should  be  used.  The 
first  operation,  if  thoroughly  performed,  will  probably  result  in 
permanent  cure.  Should  it  not,  it  may  be  repeated.  The  only 
danger  in  connection  with  it  is  the  occurrence  of  secondary 
haemorrhage  when  the  sloughs  separate,  and  of  pri- 
mary haemorrhage  from  large  veins  at  the  time  of  the 
application  of  the  iron.  To  avoid  this,  Allingham 
recommends  the  choosing  of  points  for  cauterization 
which  are  free  from  large  venous  pouches,  such  as 
may  be  visible  on  the  surface  of  the  tumor. 

In  old  cases  of  extensive  disease  the  operation  as 
thus  described  may  not  be  effectual,  and  it  may  be 
necessary  actually  to  produce  a  stricture  at  the  anus 
to  prevent  recurrence  of  the  trouble.  There  is,  per- 
haps, no  better  means  of  accomplishing  this  than  to 
apply  the  iron  to  the  whole  circumference  of  the  anus 
circularly,  instead  of  in  longitudinal  stripes ;  but 
such  an  operation  will  seldom  be  called  for. 

There  is  one  other  method  of  dealing  with  this 
affection,  which,  though  not  as  simple  as  the  cautery 
iron  alone,  is  well  worthy  of  trial,  and  that  is  Smith's 
operation  with  the  clamp  and  cautery.  We  have 
already  given  a  figure  and  description  of  the  clamp 
and  the  operation  in  speaking  of  haemorrhoids,  but 
the  operation  is  even  better  adapted  to  cases  of  pro- 
lapse than  to  haemorrhoids,  the  mass  being  larger 
and  more  readily  seized,  cut  off,  and  cauterized. 

Having  thus  described  the  most  effectual  means 
of  dealing  with  this  troublesome  affection,  it  is  scarce 
worth  while  to  describe  the  various  cutting  opera- 
tions by  which  pieces  are  removed  either  from  the 
mucous    membrane    alone,    or  from    the    sphincter 
muscle,  with  the  object  of  accomplishing  the  same 
result  that  is  more  readily  attained  with  the  cautery 
iron.     Dupuytren's  operation  consisted  in  removing  F 
three  elliptical  folds  of  skin  and  mucous  membrane    pointed  Cau- 
from  the  verge  of  the  anus.     The  same  idea  has  been 
more  recently  applied  in  Germany.'     Eobert  and  Dieffenbach 
cut  out  wedge-shaped  pieces,  and  approximated  the  edges  with 

1  Eine  neue  Methode  der  Operativen  Behandlung  des  Mastdarmvorfalls.     Deutsche 
Med.  Woch.,  No.  33,  1880. 


166  DISEASES    OF    THE    RECTUM    AND    ANUS. 

deep  sutures  ;  and  the  latter  even  went  so  far  as  to  cut  off  the 
whole  tumor — an  operation  now  seldom  practised,  except  in 
slight  cases,  such  as  those  accompanying  internal  haemorrhoids. 
Prolapse  of  the  Second  Degree. — As  already  said,  the  second 
variety  of  prolapse  differs  from  the  first  in  the  fact  that  it  is 
composed  of  the  whole  thickness  of  the  bowel,  and,  therefore, 
when  of  sufficient  length,  of  peritoneum  also.  It  is  probable 
that  every  prolapse  of  more  than  two  inches  in  length  may  con- 
tain peritoneum  ;  and  it  follows  from  the  anatomy  of  the  parts 
that' the  peritoneum  will  extend  lower  on  the  front  than  behind. 
In  the  peritoneal  pouch  thus  formed  there  may  be  located  coils 
of  intestine,  an  ovary,  or  a  part  of  the  bladder.  (See  Kectal 
Hernia.)  In  this  form  of  prolapse  there  is  no  groove  or  sulcus, 
as  is  shown  by  the  figure,  and  the  absence  of  such  a  groove  is, 
therefore,  no  proof  of  the  non-existence  of  a  fold  of  peritoneum 
in  the  tumor. 


■■•■:■■■'  ::&$' 


Fig.  63. — Prolapse  composed  of  all  the  Coats  of  the  Rectum.  (Bushe.) 

It  is  a  mistake  to  suppose  that  this  second  variety  is  not  met 
with  in  children,  for  it  is  only  an  exaggerated  form  of  the  first, 
being  the  next  step  in  the  descent  after  the  submucous  connec- 
tive tissue  has  yielded  its  utmost ;  and  exaggerated  cases  of 
prolapse  are  often  seen  in  children.  It  is  distinguished  from 
the  first  variety,  first  of  all,  by  its  size.  (Fig.  63.)  The  first  is 
never  very  large  ;  while  the  second,  from  the  nature  of  the  case, 
must  be  of  considerable  dimensions.  Again,  a  prolapse  of  the 
first  variety  is  seldom  of  long  standing,  while  one  of  the  second 
is  generally  so.  The  second  generally  follows  the  first,  but  a 
prolapse  may  be  of  this  variety  from  the  beginning  ;  resulting, 
in  such  a  case,  generally  from  violent  straining,  and  coming  on 
suddenly.     The  first  variety  is  not  firm  and  thick  to  the  feel  ; 


PROLAPSE.  107 

the  folds  of  mucous  membrane  radiate  from  the  orifice  to  the 
circumference,  and  the  opening  is  circular  and  patulous.  In 
the  second,  the  orifice  is  slit-like  and  is  drawn  backward  by  the 
attachment  of  the  meso-rectum,  or  in  females  forward  by  the 
closer  attachment  to  the  vagina.  The  form  of  the  tumor  is  con- 
ical, its  walls  are  thick  and  firm,  and  when  pressed  between 
the  fingers,  the  gurgling  of  gas  in  a  contained  loop  of  intestine 
may  sometimes  be  detected,  and  a  resonance  may  be  obtained 
on  percussion. 

If  such  a  tumor  be  carefully  dissected,  the  coats  of  the  pro- 
truded bowel  will  be  found  enlarged,  the  mucous  membrane 
will  be  seen  to  be  thickened  and  dense  in  structure,  especially 
at  the  free  extremity  ;  and  it  will,  also  sometimes  be  found 
eroded  and  granular.  The  submucous  areolar  tissue  will  be 
seen  to  be  infiltrated  with  albuminous  deposit,  and  the  muscu- 
lar layers  will  be  hypertrophied.  Owing  to  these  changes,  the 
bowel  is  actually  increased  in  size,  and  becomes  too  large  to  be 
retained  in  its  proper  place  ;  which  explains  the  difficulty  often 
experienced  in  reducing  it  and  in  keeping  it  reduced,  in  spite  of 
the  constant  straining  and  desire  for  defecation  which  it  pro- 
duces. These  changes  in  the  mucous  membrane  may  in  rare 
cases  result  in  the  production  of  a  foul,  hard,  bleeding,  eroded 
mass,  which  may  at  the  first  glance  strongly  suggest  malignant 
growth.  The  bleeding  from  a  prolapsed  rectum  is  commonly 
in  the  form  of  a  general  oozing,  and  applications  of  astringents 
may  be  necessary  for  its  control. 

Strangulation  is  rare  in  infants  and  in  feeble  old  people,  but 
in  a  strong  j3erson  the  sphincter  may  be  sufficient^  powerful  to 
produce  such  a  result.  A  strangulation  may  be  only  temporary 
when  met  by  the  proper  means,  or  it  may  continue  long  enough 
to  cause  ulceration  and  partial  gangrene ;  the  latter,  however, 
is  rare.  When  it  occurs,  it  is  possible  for  it  to  end  fatally  from 
the  contiguity  of  the  peritoneum  ;  but  it  more  often  results  in 
a  spontaneous  cure  of  the  prolapse,  and  in  a  cicatricial  stric- 
ture, the  location  of  which  will  depend  upon  the  length  of 
the  prolapsed  portion  and  the  point  at  which  the  sphacelus 
occurs. 

The  causes  of  the  second  variety  are  the  same  as  of  the  first, 
and  need  not  again  be  enumerated.  The  symptoms  also  are  the 
same,  with  the  addition  of  more  or  less  incontinence  of  faeces  in 
old  cases  ;  but  the  treatment  is  not  the  same  in  all  respects,  for 


168  DISEASES    OF   THE    RECTUM    AND    ANUS. 

certain  measures  which  may  be  safe  when  a  prolapse  contains 
no  peritoneum  may  be  fatal  under  the  opposite  condition. 

In  cases  in  which  curative  measures  are  out  of  the  question, 
the  haemorrhages  and  the  erosions  ma}^  be  relieved  by  suitable 
applications,  rest  in  bed,  defecation  in  the  recumbent  posture, 
etc.  Persulphate  of  iron  is  perhaps  as  good  an  application  to 
the  bleeding  surface  as  any  other  ;  and  weak  solutions  of  ni- 
trate of  silver  often  have  a  good  effect  upon  the  erosions.  The 
reduction  of  a  prolapse  of  the  second  degree  is  by  no  means  as 
simple  a  matter  as  that  of  the  first.  When  the  sphincter  is 
tight  and  the  tumor  cedematous,  it  may  be  nearly  impossible ; 
and  in  old  cases,  where  the  opposite  condition  of  the  sphincter 
obtains,  it  may  be  equally  difficult  to  keep  the  parts  within  the 
body  after  placing  them  there.  The  latter  may,  however,  gen- 
erally be  accomplished  by  the  means  already  enumerated,  and 
the  reduction  in  obstinate  cases  may  generally  be  obtained 
through  the  influence  of  anaesthesia. 

Two  questions  may  arise  in  this  connection.  Should  reduc- 
tion be  tried  when  the  tumor  is  inflamed,  and  should  it  be  tried 
in  case  of  a  circular  slough?  In  answering  the  first  question, 
the  distinction  must  be  made  between  a  prolapse  which  is 
merely  strangulated  and  one  which  is  inflamed.  The  appear- 
ances may  be  much  the  same,  but  an  old  prolapse  in  an  old 
person  when  found  in  this  condition  is  much  more  apt  to  be 
inflamed  than  strangulated,  for  the  sphincter  muscle  in  such 
cases  has  generally  lost  the  power  of  forcible  constriction.  The 
danger  in  returning  an  inflamed  prolapse  into  the  body  is  that 
the  inflammation  may  extend  and  cause  general  and  fatal  peri- 
tonitis, and,  as  a  rule,  it  is  safer  not  to  employ  the  taxis  in  such 
a  case,  but  to  put  the  patient  in  bed  and  treat  it  by  local  appli- 
cations and  rest  till  the  acute  symptoms  have  disappeared. 

In  answer  to  the  second  question,  Molliere '  recommends  ex- 
tirpation of  the  prolapsed  portion  rather  than  its  reduction 
when  there  is  a  circular  slough,  on  the  ground  that  no  matter 
how  radical  such  a  step  may  appear  at  first  sight,  it  is  better 
than  leaving  the  case  to  nature.  For  a  circular  slough  means 
inevitably  a  cicatricial  stricture,  and  if  the  prolapse  be  exten- 
sive, a  stricture  situated  high  up  in  the  rectum  or  sigmoid  flex- 
ure beyond  the  reach  of  art.     As  preferable  to  this  he  recom- 

1  Op.  cit. ,  p.  240. 


PROLAPSE.  169 

mends  the  complete  ablation  of  the  tumor  with  all  the  dangers 
which  attend  such  a  step.  These  dangers  are  easily  understood 
to  be  haemorrhage,  hernia  of  the  intestines  through  the  incision, 
and  peritonitis.  Each  may  be  avoided  where  the  surgeon  is 
prepared  beforehand  for  their  occurrence,  and  Molliere  relates 
one  case  where  the  operation  was  performed  by  himself  with  the 
hot  iron,  but  the  patient  "died  on  the  eighth  day  from  the  ef- 
fects of  the  chloroform  ' '  so  that  he  was  unable  to  decide  on  the 
value  of  the  operation. 

Excision  with  the  surgeon's  eyes  open  to  the  fact  that  he  is 
dealing  with  peritoneum  may  perhaps  be  done  with  success 
under  such  circumstances.  At  all  events  it  is  a  very  different 
matter  from  excision  of  this  variety  of  prolapse  under  the  im- 
pression that  it  is  the  one  previously  described,  and  contains  no 
peritoneum. 

In  this  form  of  the  disease,  the  surgeon  may  find  it  better, 
after  mature  deliberation,  not  to  attempt  a  radical  cure,  but  to 
confine  his  efforts  solely  to  palliation. 

Dr.  Kleberg  has  utilized  the  elastic  ligature  in  operating  upon 
severe  cases  of  prolapse  ;  and,  it  may  be,  that  if  the  mass  has 
to  be  removed  at  all,  the  method  he  describes  (p.  208)  is  the  pre- 
ferable one. 

Third  and  Fourth  Varieties. — These  two  forms  of  invagina- 
tion will  be  described  together  because  of  the  fact  that  they 
differ  from  each  other  not  at  all  in  their  nature  but  only  in  ex- 
tent and  location.  It  will  be  observed  that  the  word  prolapse  is 
now  dropped  and  invagination  substituted,  which  more  aptly 
expresses  the  condition.  The  essential  difference  between  the 
disease  now  to  be  considered  and  the  forms  already  described, 
consists  in  the  fact  that  while  in  the  latter  the  bowel  begins  to 
slip  down  from  its  lowest  portion  at  the  anus,  in  the  former  the 
lowest  portion  at  the  anus  remains  in  its  proper  position  and  the 
bowel  from  above  is  telescoped  within  it.  Under  these  circum- 
stances it  is  evident,  as  is  shown  in  Fig.  60,  that  the  affected 
portion  of  the  bowel  must  consist  of  three  different  and  distinct 
cylinders — an  outer  one,  which  contains  the  other  two,  and  two 
included  portions,  one  of  which  is  the  entering  and  the  other 
the  returning  bowel. 

When  the  upper  part  of  the  rectum  becomes  invaginated  in 
this  way  within  the  lower,  the  included  portion  will  appear  at 
the  anus  as  in  the  cases  of  prolapse  already  described,  and  a 


170 


DISEASES    OF    THE    EECTUM    AND    ANUS. 


distinct  sulcus  may  be  felt  by  the  finger  between  the  extruded 
portion  and  the  mucous  membrane  which  is  continuous  with 
that  of  the  anus.  (Fig.  64.)  The  bottom  of  this  sulcus,  or  the 
point  at  which  the  entering  portion  becomes  directly  continuous 
with  that  into  which  it  enters  may  also  be  felt  by  the  finger  if 
it  is  low  enough  down  ;  if  not,  it  may  be  detected  by  the  aid  of 
a  soft  catheter.  This  is  what  is  understood  by  the  third  variety 
of  prolapse.  When  a  portion  of  the  bowel  still  further  removed 
from  the  anus  has  become  invaginated  into  that  immediately 


Pig.  04.— Prolapse  of  Invaginated  Intestine.    (Esmarch.) 

below,  the  included  portion  mayor  may  not  descend  sufficiently 
Dear  to  the  anus  to  be  felt  by  rectal  touch,  and  the  sulcus  may 
not  be  apparent.  This  constitutes  the  fourth  variety,  or  what 
is  now  generally  known  as  intussusception.  It  is  evident  that 
between  a  case  of  prolapse  in  which  all  the  coats  of  the  rectum 
appear  through  the  anus,  and  in  which  a  sulcus  can  be  felt  by 
the  finger  passed  around  the  protruded  portion,  and  a  case  in 
which  the  ileum  is  telescoped  through  theilio-csecal  valve  and  ap- 
pears at  the  anus,  the  difference  is  one  of  degree  and  not  of  kind. 


PROLAPSE.  171 

Of  tins  condition  there  are  many  degrees,  and  almost  any 
portion  of  the  bowel  from  the  duodenum  to  the  rectum  may  be- 
come invaginated  into  the  portion  next  below.  The  caecum 
itself  may  be  so  loosened  from  its  attachments  as  to  follow  the 
same  course,  and  the  orifice  of  the  appendix  vermiformis  may 
be  detected  at  the  anus  by  the  side  of  the  orifice  of  the  included 
bowel. 

In  763  cases  of  invagination  collected  by  Bultean,1  220  were 
of  the  small  intestine,  151  of  the  large,  and  392  ileo-csecal. 

The  mesentery  of  the  two  included  portions  is  drawn  in  with 
them,  and  by  its  attachment  and  traction  gives  to  them  a  curve 
the  concavity  of  which  is  toward  the  point  of  attachment  of 
the  mesentery.  For  this  reason  the  lower  orifice  of  the  in- 
cluded portion  is  not  found  in  the  axis  of  the  containing 
portion,  but  turned  toward  some  portion  of  its  circumference, 
and  is,  therefore,  often  difficult  to  detect  by  digital  examina- 
tion. 

The  immediate  effect  of  an  invagination  is  to  interfere  with 
the  passage  of  fseces,  but  seldom  to  entirely  prevent  their  pas- 
sage, for  the  fasces  do  pass,  and  in  considerable  quantity,  forced 
down  through  the  constriction  by  the  contraction  of  the  healthy 
bowel  above. 

Another  immediate  effect  which  is  due  to  constriction  of  the 
blood-vessels  in  the  included  mesentery  and  in  the  walls  of  the 
included  portion,  is  the  transudation  of  serum  and  consequent 
swelling  of  the  intestinal  walls.  By  this  means  the  serous  sur- 
faces become  dark-colored,  and  the  mucous  surfaces  become  in- 
filtrated ;  blood  is  effused  between  the  mucous  surfaces  of  the 
outer  and  middle  layers,  and  lymph  between  the  serous  surfaces 
of  the  middle  and  internal  layers,  and  after  a  time  these  become 
completely  agglutinated. 

If  the  constriction  be  sufficiently  severe,  the  included  por- 
tions soon  become  gangrenous  and  slough  away,  the  lumen  of 
the  bowel  is  again  established,  and  a  circular  cicatrix  is  left. 
This  is  nature's  method  of  cure,  and  though  life  is  by  it  saved 
for  a  time,  in  the  end  the  cicatrix  thus  formed  may  become  a 
stricture  which  shall  be  more  surely  fatal  than  the  condition 
from  which  it  arose.  The  invaginated  portion  is  at  first  of  ne- 
cessity short ;  but  as  the  case  advances,  it  may  reach  to  several 

1  De  l'occlusion  intestinale  au  point  de  vue  du  diagnostic  et  du  traitenient.  These 
de  Paris,  1878. 


172  DISEASES    OP    THE    RECTUM    AND    ANUS. 

feet,  and  in  one  case '  there  is  reason  to  believe  that  about  four 
yards  of  intestine  came  away,  piece  by  piece,  per  anum. 

The  disease  is  twice  as  common  in  males  as  in  females,  and  is 
greatly  more  common  in  children  than  in  adults.  In  adults  the 
trouble  will  generally  be  found  to  involve  the  small  intestine  ; 
in  children,  the  large.  An  invagination  of  the  small  into  the 
large  intestine  begins  generally  at  the  ileo-csecal  valve,  which 
with  the  vermiform  appendix  is  carried  up  the  ascending,  and 
along  the  transverse  colon,  till  it  may  finally  reach  the  anus  and 
protrude  through  it,  the  valve  all  the  time  remaining  the  lowest 
portion.  In  these  cases  only  the  inner  tube  is  made  of  small  in- 
testine, the  middle  and  the  outer  consisting  of  the  large. 

Strangulation  is  much  more  frequent  where  the  outer  layer 
is  composed  of  the  small  than  where  it  is  composed  of  the  large 
intestine ;  because  of  the  greater  tightness  of  the  constriction. 
In  the  latter  case  the  congestion  may  be  only  moderate  in  degree 
and  the  condition  may  last  many  weeks  without  gangrene  or 
ulceration.     This  condition  is  known  as  chronic  intussusception. 

If  sloughing  occur  at  all,  it  may  happen  at  any  time  after 
the  first  week  ;  generally,  however,  it  occurs  within  three  weeks, 
though  it  maybe  delayed  for  a  much  longer  time.  In  one  case" 
the  separation  of  fragments  of  intestine  extended  over  an  inter- 
val of  three  years. 

In  about  one-half  of  the  reported  cases  a  favorable  termina- 
tion has  followed  spontaneous  separation,  in  the  remainder 
death  has  occurred  after  a  longer  or  shorter  interval.  Several 
pathological  changes  may  occur.  The  peritonitis  which  serves 
to  unite  the  serous  surfaces  of  the  contained  portions  may  be- 
come general  and  cause  death.  The  ensheathing  portion  may  be- 
come ulceiated  and  perforated,  allowing  of  the  extravasation  of 
fseces.  The  ulceration  may  perhaps  be  due  to  the  lateral  press- 
ure of  the  end  of  the  contained  portion  against  the  side  of  the 
cylinder  which  contains  it.8  Separation  by  sloughing  leaves  the 
upper  end  of  the  ensheathing  portion  united  with  the  lower  end 
of  the  lnalthy  bowel,  and  results  in  complete  amputation  of  the 
contain<  d  portion.  Extravasation  may  also  occur  from  a  defi- 
cienrv  in  this  union  at  the  time  when  separation  occurs. 

The  causes  of  invagination  are  not  as  yet  perfectly  under- 
stood.    It  is  easy  to  understand  how  in  the  effort  which  the  in- 

1  Peacock  :  Path.   Trans.,  vol.  xv.  s  Peacock,  loc.  cit. 

3  Aitken  :  Practice  of  Medicine,  vol.  ii. 


PROLAPSE.  173 

testine  makes  to  relieve  itself  of  a  polypus  or  other  tumor  by  its 
vermicular  action,  not  only  the  growth  itself  may  be  extruded, 
but  also  the  portion  of  the  bowel  to  which  it  is  attached  ;  and 
polypus  is  one  of  the  recognized  causes  of  this  condition.  But 
in  the  great  majority  of  cases  no  such  palpable  cause  is  to  be  de- 
tected. Except  in  the  case  of  a  tumor  it  is  probably  always  an 
accident  of  sudden  occurrence  dependent  upon  some  violent 
action  in  that  part  of  the  bowel.  A  collection  of  gas  causing  an 
undue  dilatation  in  one  part  of  the  intestine,  combined  with  a 
violent  movement  of  the  abdominal  muscles,  and  a  peristaltic 
movement  in  the  portion  just  above  that  which  is  distended, 
might,  it  is  easily  understood,  cause  the  accident.  So,  also, 
might  any  interference  with,  or  undue  violence  in,  the  rhythmic 
action  of  natural  peristalsis,  by  which  the  bowel  in  successive 
portions  is  first  shortened  and  dilated  by  contraction  of  the 
longitudinal  fibres,  and  then  narrowed  and  elongated  by  the 
contraction  of  the  circular  fibres.  Since  the  wave  of  peristaltic 
action  is  constantly  passing  from  above  downward,  it  may  easily 
happen  that  a  narrowed  portion  may  under  unfavorable  circum- 
stances be  caught  in  a  dilated  portion  just  below,  and,  once  en- 
gaged, the  exaggeration  of  the  condition  becomes  natural  and 
easily  understood.  It  is  to  such  explanations  as  this  that  we 
have  to  look  in  the  absence  of  any  palpable  cause. 

Symptoms. — An  invagination  will  cause  a  very  different  train 
of  symptoms,  according  to  the  part  of  the  bowel  affected  and 
the  intensity  of  the  constriction.  As  a  rule,  the  symptoms  are 
more  acute  and  severe  in  invagination  of  the  small  intestine,  and 
are  more  chronic  in  the  large,  because  the  constriction  is  more 
intense  in  the  former  than  in  the  latter  ;  but  an  invagination  of 
the  small  intestine  may  approach  in  symptoms  and  chronicity 
to  one  of  the  large,  and  vice  versa. 

Wherever  the  constriction  be  located,  its  first  symptom  is 
generally  a  sharp  attack  of  pain  in  the  abdomen,  coming  on 
suddenly,  and  often  in  the  midst  of  perfect  health.  There  is 
nothing  characteristic  in  this  pain.  It  may  pass  off  after  a  few 
hours  and  again  return  ;  it  may  or  may  not  be  accompanied  by 
vomiting  at  the  start ;  it  is  sometimes  relievable  by  direct  press- 
ure, and  it  is  not  at  first  accompanied  by  any  tenderness  of  the 
abdomen. 

Change  in  the  character  of  the  evacuations  is  also  a  symptom 
common  to  the  disease  in  any  part.     After  the  onset  there  will 


174  DISEASES    OF   THE    RECTUM    AXD    ANUS. 

still  be  a  discharge  of  the  contents  of  the  bowel  below  the  con- 
striction, and  a  certain  amount  of  faeces  may  still  leak  through 
the  invagination.  Instead  of  the  natural  passages,  however,  the 
appearance  of  bloody  stools  is  a  very  common  occurrence,  the 
blood  coming,  as  has  already  been  explained,  from  the  con- 
gested and  swollen  mucous  membrane  of  the  outer  and  middle 
portions.  There  is  also  present  at  times  a  dysenteric  discharge 
and  a  good  deal  of  tenesmus. 

By  careful  manual  examination,  a  tumor  can  generally  be 
discovered  in  the  abdomen,  which  may  be  characteristic  enough 
to  form  a  basis  for  the  diagnosis  ;  but  this  may  be  concealed  by 
the  presence  of  much  fat,  or  by  a  general  distention  of  the 
abdomen  with  gas.  The  tumor  is  cylindrical,  and  may  be 
movable  under  the  hand  from  its  own  peristaltic  action,  or  it 
may  be  seen  to  change  its  position  from  day  to  day  as  the  in- 
vagination gradually  advances,  and  more  and  more  of  the 
bowel  becomes  involved. 

The  other  symptoms  depend  in  great  measures  upon  the 
severity  of  the  strangulation,  and,  as  has  been  said,  are  more 
marked  when  the  small  intestine  is  implicated.  In  such  cases, 
the  symptoms  rapidly  increase  in  severity.  There  may  or  may 
not  be  considerable  febrile  action;  the  abdomen  soon  becomes 
tender  to  the  touch  ;  there  is  almost  complete  obstruction,  or 
else  only  the  passage  of  bloody  mucus  ;  the  patient  rapidly 
sinks,  and  the  history  ends  either  in  death  or  in  the  sloughing 
of  the  included  part.  The  latter  is  shown  by  a  re-establishment 
of  the  calibre  of  the  bowel,  and,  therefore  of  the  passages  ;  by 
an  abatement  of  all  the  worst  symptoms,  and  finally  by  the 
appearance  of  larger  or  smaller  pieces  of  gangrenous  intestine 
in  the  passages. 

The  existence  and  the  early  appearance  of  faecal  vomiting 
have  been  given  as  points  in  favor  of  the  diagnosis  of  intussus- 
ception  of  the  small  rather  than  of  the  large  intestine  ;  but  they 
point  rather  toward  complete  obstruction  than  to  the  particular 
s^at  of  the  obstruction. 

In  invagination  of  the  large  intestine,  the  general  history 
of  the  case  is  that  of  a  more  chronic  trouble.  The  pain  is  less 
severe  and  the  paroxysms  separated  by  longer  intervals  ;  the 
faecal  evacuations  are  larger,  and  the  dysenteric  symptoms  are 
more  pronounced  ;  vomiting  is  variable,  and  after  a  time  often 
stercoraceous.    This  state  may  continue  for  several  weeks  before 


PROLAPSE.  175 

death  results  from  gradual  exhaustion  or  from  the  supervention 
of  acute  strangulation.  The  history  of  a  case  of  chronic  invag- 
ination may  at  any  time  be  cut  short  by  the  occurrence  of  a 
general  acute  peritonitis,  and  this  is  particularly  apt  to  happen 
at  the  time  of  the  separation  of  the  slough. 

Diagnosis. — In  any  case  in  which  the  invaginated  portion 
descends  near  enough  to  the  anus  to  be  felt  by  digital  examin- 
ation, the  diagnosis  is  easy  to  the  surgeon  of  ordinary  care  and 
intelligence  who  has  studied  the  symptoms  which  infallibly 
point  in  the  direction  of  intestinal  occlusion.  But  when  such  an 
examination  has  been  made  with  a  negative  result,  beyond  the 
fact  that  occlusion  exists,  the  surgeon  may  be  completely  at  a 
loss.  Under  such  circumstances  the  differential  diagnosis  rests 
between  the  following  conditions:  1,  Invagination;  2,  Vol- 
vulus ;  3,  Stricture  ;  4,  Concealed  internal  hernia  ;  5,  Pressure 
from  without  the  bowel  by  tumors,  etc. ;  6,  Obstruction  from 
foreign  bodies,  as  calculi,  indurated  faeces,  etc. ;  7,  Peritonitis 
from  perforation.  It  may  be  as  well  to  state  at  once  that  in 
these  cases  the  differential  diagnosis  will  often  be  impossible, 
and  then  go  on  to  throw  what  light  upon  the  question  modern 
science  has  made  available.  It  is  a  good  plan  to  divide  all 
cases  of  intestinal  obstruction  into  the  acute  and  the  chronic. 
An  acute  case  will  generally  be  either  an  invagination,  a  vol- 
vulus, or  an  internal  hernia.  Duplay  '  also  has  called  attention 
to  the  fact  that  a  peritonitis  from  perforation  may  cause  all 
the  symptoms  of  an  acute  occlusion,  and  has  given  the  chief 
points  in  the  diagnosis  of  that  affection.  In  peritonitis  the 
vomiting  seldom  becomes  faecal,  but  remains  bilious  to  the  end  ; 
the  constipation  is  less  marked  and  the  patient  generally  passes 
gas  and  liquid  faeces  or  small  quantities  of  solid  matter  ;  the 
tympanites  is  also  less  marked,  and  the  coils  of  intestine  are 
less  pronounced  ;  the  pain  begins  with  great  severity  at  one 
point,  and  extends  over  the  whole  abdomen  (the  same  tiling 
may  happen  in  acute  obstruction,  but  in  such  cases  the  other 
symptoms — faecal  vomiting,  absolute  constipation,  absence  of 
the  passage  of  gas  per  anum — are  all  equally  severe,  while  in 
peritonitis  they  do  not  correspond  in  severity  with  the  intensity 
of  the  pain)  ;  the  temperature  is  elevated  in  peritonitis  and 
normal  or  even  less  than  normal  in  obstruction. 

1  Dnplay :  Du  Traitement  Chirurgical  de   l'Occlusic-n  Intestinal.     Arch.  Gen.  de 
Med.,  December,  1879. 


176  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Having  then  excluded  peritonitis  from  perforation,  the  diag- 
nosis in  any  acute  case  will  rest  between  invagination,  volvulus, 
and  internal  hernia.  Invagination  is  indicated  by  the  signs  of 
partial  occlusion,  by  the  moderate  tympanites,  by  the  bloody 
stools  mixed  with  mucus,  the  tenesmus,  and  the  presence  of  the 
tumor.  The  diagnosis  between  volvulus  and  internal  hernia 
will  generally  be  impossible  except  as  the  history  may  point 
to  antecedent  peritonitis,  or  to  a  hernia  which  has  ceased  to 
come  down  ;  or  as  the  careful  exploration  of  the  abdomen  by 
palpation  and  of  the  pelvis  by  rectal  and  vaginal  touch  may 
show  the  existence  of  an  induration  or  resistance  limited  to  one 
point. 

In  other  words,  in  any  acute  case  of  occlusion  the  existence 
of  invagination  may  be  decided  by  the  presence  or  absence  of 
its  peculiar  symptoms,  and  if  excluded  the  diagnosis  rests  either 
with  volvulus  or  internal  hernia,  but  with  Avhich  it  may  be  im- 
possible to  decide. 

In  a  case  of  chronic  intestinal  occlusion,  the  diagnosis  rests 
between  invagination,  occlusion  by  the  pressure  of  solid  or  fluid 
tumors  outside  the  bowel,  stricture  of  the  intestine,  abnormal 
adhesions  of  the  bowel,  and  obstruction  by  foreign  bodies  within 
the  bowel,  such  as  biliary  calculi,  indurated  faeces,  tumors,  etc. 
The  easiest  of  these  to  diagnosticate  is  that  which  comes  from 
the  pressure  of  a  tumor  without  the  bowel.  Chronic  invagina- 
tion may  be  made  out  by  the  symptoms  already  given.  For 
the  symptoms  of  stricture,  we  must  refer  the  reader  to  the 
chapter  on  that  subject,  and  these  symptoms  are  much  the 
same  whether  the  obstruction  be  due  to  a  narrowing  of  the  cali- 
bre of  the  bowel  by  a  deposit  in  its  wall,  or  to  the  presence  of  a 
foreign  body,  or  abnormal  adhesions  of  the  peritoneum  which 
cause  acute  flexures  and  obstructions  in  its  calibre. 

It  will  thus  be  seen  that  the  differential  diagnosis  is  shrouded 
in  difficulty,  and  that  the  difficulty  is  rather  greater  in  a  case  of 
chronic  than  of  acute  obstruction.  A  well-marked  case  of  in- 
vagination, whether  acute  or  chronic,  is,  however,  the  easiest  of 
all  the  forms  of  occlusion  to  distinguish,  and  the  diagnosis  can 
generally  bu  made  with  sufficient  approach  to  certainty  to  guide 
the  surgeon  in  the  selection  of  his  plan  of  treatment. 

Treatment. — It  is  evident  that  the  treatment  of  the  conditions 
we  have  been  describing  must  differ  in  every  particular  from 
that  of  those  previously  described.     When  the  invagination  has 


PROLAPSE.  177 

occurred  in  the  rectum,  that  is,  when  the  upper  part  of  the  rec- 
tum has  become  telescoped  into  the  lower,  and  has  appeared  as 
a  prolapsed  mass  outside  of  the  anus,  the  case  may  still  be  re- 
lievable  by  the  methods  of  reduction  and  taxis.  The  mass  must 
be  replaced  by  a  process  exactly  the  reverse  of  the  one  by  which 
it  came  down,  the  most  dependent  portion  being  first  carried 
into  the  body,  and  the  entanglement  unfolded  in  this  way.  In 
a  child,  with  the  assistance  of  anaesthesia,  the  inverted  position, 
and  gentle  manipulation  with  the  fingers,  or  possibly  with  a  soft 
bougie,  this  may  sometimes  be  accomplished  where  the  point  of 
constriction  is  low  down  near  the  anus.  Prall1  reports  a  case 
where  replacement  was  successfully  accomplished  by  manipula- 
tion with  the  tube  of  a  stomach-pump,  though  the  mass  could 
only  just  be  felt  in  the  rectum. 

In  cases,  whether  of  adults  or  children,  where  the  constric- 
tion is  still  higher  in  the  intestine,  and  manipulation  with  the 
hand  or  bougie  is  out  of  the  question,  various  other  mechanical 
means  may  be  tried  with  a  prospect  of  success.  These  consist 
in  applying  indirect  pressure  to  the  invaginated  portion  and  to 
the  constricting  part  by  means  of  copious  injections  of  water  or 
air,  but  it  should  be  understood  that  they  are  only  applicable 
to  cases  affecting  the  large  intestine  alone,  and  the  lower  down 
in  the  large  intestine  the  constriction  may  be,  the  better  is  the 
prospect  of  their  success.  In  cases  of  this  kind  the  mechanical 
treatment  may  be  assisted  by  the  previous  administration  of 
opium  and  belladonna  in  full  doses,  the  one  to  quiet  peristalsis, 
the  other  to  relax  the  unstriped  muscular  fibres  of  the  intestine. 
To  these  means  may  be  added  the  reversal  of  position  and  an- 
aesthesia, and  then  the  copious  injection  of  large  quantities  of 
warm  fiuid,  or  of  air  by  means  of  a  bellows,  may  in  a  few  cases 
be  successful. 

The  following  case  illustrates  the  method  of  treatment  by 
injection,  and  what,  under  favorable  circumstances,  may  be 
accomplished  hy  it.2 

Case.  —  Invagination. — A  well- nourished  infant,  seven 
months  old,  was  in  perfect  health  till  noon  of  the  day  of 
attack,  when  she  suddenly  screamed,  and  immediately  after- 
ward became  pale,  cold,  and  collapsed.  She  was  put  into  a 
warm  bath,  after  which  she  lay  quietly  in  the  nurse's  arms  for 

1  Brit.  Med.  Journ.,  July  31,  1880. 

2  Dr.  N.  P.  Blaker,  Brit.  Med.  Journ.,  January  11,  1879. 
12 


178  DISEASES    OF    THE    RECTUM   AND    ANUS. 

an  hour  and  a  half,  the  bowels  acting  slightly  once  or  twice. 
At  3  p.m.  the  child  had  become  warmer,  and  was  sleeping 
quietly,  occasionally,  however,  waking  up  with  a  scream,  and 
drawing  up  her  legs  with  an  expression  of  severe  pain.  There 
was  occasional  vomiting,  and  at  6  p.m.  two  passages  of  bloody 
mucus.  At  11  p.m.  a  distinct  but  ill-defined  oval  tumor,  about 
an  inch  and  a  half  in  its  longest  diameter,  could  be  felt  through 
the  parietes,  at  a  spot  two  inches  to  the  left  of  the  umbilicus. 
A  considerable  quantity  (perhaps  a  drachm)  of  dark  blood  came 
away,  and  it  was  determined  to  distend  the  large  intestine  with 
thin  gruel.  The  child  was  put  thoroughly  under  the  influence 
of  chloroform,  and  placed  on  the  table,  with  the  nates  well  raised 
on  a  pillow.  The  gruel  was  slowly  injected  by  means  of  a  Hig- 
ginson's  syringe,  the  upper  part  of  the  nozzle  being  pressed 
firmly  against  the  anus  to  prevent  any  from  escaping.  After  a 
pint  or  more  had  been  injected,  the  abdomen  became  tense,  and 
the  distended  bowel  could  be  felt  like  a  hard  rope,  an  inch  in 
diameter,  across  the  upper  part  of  the  abdomen,  almost  as  far 
as  the  right  iliac  region,  and  considerable  force  would  have 
been  required  to  inject  any  more  of  the  fluid.  When  the  nozzle 
of  the  syringe  was  removed,  a  portion  of  the  gruel  escaped,  and 
soon  afterward  a  much  larger  quantity.  The  child  slept  well 
at  intervals  during  the  night,  took  the  breast  well,  and  there 
was  neither  vomiting  nor  pain.  Next  morning  the  skin  was  a 
little  hot  and  the  pulse  a  little  quick,  and  one  small  healthy 
motion  had  been  passed.  The  tumor  which  had  been  felt  in  the 
abdomen  had  disappeared.  At  1  p.m.  all  the  feverish  symptoms 
had  disappeared,  and  the  child  had  passed  a  copious  motion  of 
green  color,  and  there  had  been  no  pain  or  spasm.  At  4  p.  m. 
there  was  another  large  motion  of  the  same  character.  From 
this  time  the  child  appeared  in  perfect  health,  but  the  motions 
retained  their  unhealthy  look  for  four  days  longer. 

The  success  of  this  treatment  undoubtedly  depended  in  a 
great  measure  upon  the  speed  with  which  it  was  adopted  before 
reduction  became  difficult  from  strangulation. 

Instead  of  warm  gruel  the  enema  may  consist  of  simple 
water,  or  of  soda-water  from  a  siphon,  or  of  a  portion  of  a  seid- 
litz  powder,1  the  idea  in  the  latter  case  being  to  gain  the  disten- 
tion by  the  gas  as  well  as  by  the  water.    A  good  formula  when 

1  Case,  Dr.  Morton,  Practitioner,  July,  1875. 


PROLAPSE.  179 

it  is  desired  to  make  use  of  the  pressure  of  gas  is  two  parts  of  a 
solution  of  bicarbonate  of  soda,  and  one  of  tartaric  acid  in- 
jected separately.  There  are  now  many  cases  recorded  in  which 
these  means  have  been  successful,  and  the  relief  following  such 
a  procedure  has  been  instantaneous  ;  but,  as  a  rule,  injections 
of  fluid  are  more  easily  managed,  the  amount  of  pressure 
produced  by  them  better  gauged,  and,  therefore,  they  are  safer. 
There  is  much  to  be  said  against  the  practice  of  trying  to  re- 
lieve the  condition  of  distention  by  puncture  of  the  intestine, 
though  Broadbent  reports  a  very  successful  case  in  which  cure 
was  affected  by  that  means.  The  danger  is  that  fsecal  extrava- 
sation may  occur,  and  to  guard  against  this  he  offers  the  follow- 
ing suggestions  :  1.  To  secure,  if  possible,  absolute  freedom 
from  peristalsis  by  an  extra  dose  of  opium.  2.  To  select,  if 
possible,  a  coil  of  intestine  which  shall  contain  only  gas  and 
not  liquid.  This  will  be  found  (if  anywhere)  in  the  jejunum, 
and  therefore  above  and  not  below  the  umbilicus.  An  indis- 
pensable condition  is  that  scarcely  any  food  sliall  ham  been 
taken  during  the  entire  attack.  3.  To  pierce  the  coil  exactly  at 
its  most  convex  part.  The  abdomen  should  be  carefully 
watched  for  some  time  at  every  visit,  and  especially  before  the 
operation.  In  some  cases  where  the  walls  are  thin  the  outlines 
of  various  coils  may  be'  traced  even  in  repose  ;  but  this  will  be 
more  distinct  when  peristalsis  is  provoked  by  pressure  or  man- 
ipulation of  any  kind ;  it  will  be  seen  also  which  coils  shift  and 
which  keep  the  same  position  when  contracting.  The  spot 
chosen  for  puncture  should  be  as  near  as  possible  over  the 
centre  of  a  coil  which  does  not  roll  about,  and  by  preference  in 
the  linea  alba.  4.  To  exercise  great  care  and  patience  during 
the  escape  of  gas.  The  needle  should  be  held  lightly,  but  rather 
firmly,  perpendicular  to  the  abdominal  wall,  and  should  not  be 
allowed  to  follow  too  freely  the  rolling  of  the  coil  of  intestine. 
As  the  gas  escapes  from  the  coil  which  has  been  punctured,  it 
will  collapse,  and  the  flow  from  the  needle  will  cease  ;  very 
soon,  however,  the  air  in  the  intestine  will  distribute  itself  and 
enter  the  empty  portion,  when  it  will  again  escape.  This  may 
be  aided  by  gentle  manipulation  and  pressure.  Should  the 
tube  get  blocked,  aspiration  may  free  it ;  but  it  is  safer  to  drive 
a  little  air  through  the  tube  into  the  bowel  than  to  exert  power- 
ful suction  which  may  draw  the  mucous  membrane  against  the 
point  of  the  needle. 


180  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Dr.  Broadbent,  in  spite  of  the  rules  for  its  use  which  he  has 
laid  down,  believes  that  puncture  can  relieve  obstruction  only 
very  exceptionally.  His  own  experience  leads  him  to  recom- 
mend it  as  a  palliative,  and  he  suggests  that  it  may  be  a  useful 
preliminary  to  inflation,  manipulation,  suspension  in  the  in- 
verted position,  etc.,  in  the  treatment  of  intussusception. 

The  chief  hope  of  relieving  an  invagination,  however,  lies  in 
prompt  and  efficient  surgical  interference  by  opening  the  abdo- 
men. The  propriety  of  such  a  course  has  in  the  last  few  years 
been  the  subject  of  much  argument.  In  its  favor  have  been  ad- 
duced the  rarity  of  ultimate  recovery  from  the  disease,  even 
after  sloughing  of  the  included  portion  and  temporary  relief  ; 
the  fact  that  when  the  large  intestine  is  affected  the  bowel  may 
remain  in  a  comparatively  healthy  state  for  weeks,  and  above 
all,  the  actual  saving  of  life  which  has  now  sufficiently  often 
followed  the  performance  of  the  operation  to  attest  its  undoubted 
value.  Against  the  operation  still  stand,  however,  the  difficulty 
of  positive  diagnosis,  especially  early  in  the  disease,  the  speedy 
formation  of  such  adhesions  as  will  prevent  reduction  even  after 
the  abdomen  has  been  opened,  and  the  early  supervention  of 
gangrene  which  renders  reduction  improper,  and  the  compara- 
tive frequence  of  spontaneous  recovery  by  sloughing. 

At  the  present  time  it  is  admitted  that  in  cases  of  acute  or 
chronic  invagination,  where  the  diagnosis  is  reasonably  certain, 
and  where  the  means  of  relief  which  have  been  enumerated 
have  been  tried  and  failed,  the  abdomen  should  be  opened. 
The  discussion  at  present  has  changed  its  bearings  to  the  ques- 
tion of  abdominal  section  where  the  diagnosis  as  to  the  form  of 
obstruction  cannot  be  arrived  at.  The  surgeon  having  deter- 
mined to  operate,  no  time  is  to  be  lost ;  for  success,  if  the  oper- 
ation be  successful,  will  depend  more  than  anything  else  upon 
the  time  at  which  the  operation  is  done. 

The  operation  of  laparotom}^,  or  oj)ening  the  abdominal  cav- 
ity, is  to  be  performed  as  follows  :  The  incision  should  be  about 
five  inches  long,  in  the  llnea  alba,  above  the  umbilicus.  The 
tissues  should  be  divided  slowly,  and  all  bleeding  should  be 
stopped  before  the  peritoneum  is  ojDened  on  a  director  to  an 
extent  equalling  the  opening  in  the  skin.  The  seat  of  the  ob- 
struction is  to  be  sought  for  by  first  noticing  the  condition  of 
the  caecum.  If  this  be  flaccid,  the  obstruction  is  in  the  small 
intestine,  if  it  be  distended  it  is  in  the  large.     If  the  caecum  be 


PROLAPSE.  181 

found  undistended  the  hand  is  to  be  passed  gradually  along  the 
small  intestine  till  the  obstruction  is  encountered  ;  if  the  oppo- 
site condition  obtains,  v  the  ascending  transverse,  and  descend- 
ing colon  are  to  be  successively  examined. 

When  the  invagination  has  been  found,  it  should  be  un- 
folded, as  Hutchinson  suggests,  rather  by  expressing  the  in- 
cluded portion  out  of  its  sheath  from  below  upward,  than  by 
traction  upon  it  from  above.  If  the  bowel  should  be  found  per- 
forated, or  gangrenous  in  any  part  so  that  perforation  seems 
probable,  an  artificial  anus  is  to  be  formed  by  stitching  the 
bowel  to  the  lowest  part  of  the  abdominal  wall. 


CHAPTER  VIII. 

RECTAL   HERNIA. 

Definition. —Generally  a  Complication  of  Prolapsus. — Cases. — Anatomy. — The  Pelvic 
Diaphragm. — Relation  of  Pelvic  Diaphragm  to  Rectal  Hernia. — Varieties  of  Rec- 
tal Hernia. — Internal  and  External  Hernia.— Hernia  without  a  Sac. — Rupture  of 
the  Rectum  usually  a  Result  of  Hernia.— Changes  in  Sac  which  lead  to  Rupture. 
— Location  and  Extent  of  Rupture. — Cause  of  Rupture. — Contents  of  Hernial  Sac. 

. Hernia  may  be  Reducible,  Irreducible,  Inflamed,  or  Strangulated. — Causes  of 

Irreducibility. — Symptoms  of  Inflamed  Hernia. — Seat  of  Constriction  in  Strangu- 
lation.— Diagnosis. — Treatment. — Method  of  Reduction. — Operations  for  Radical 
Cure. — Kleberg's  Operation  with  Elastic  Ligature. — Treatment  of  Inflamed  Her* 
nia. — Treatment  of  Strangulation. — Incision  into  Sac. — Laparotomy. — Treatment 
after  Rupture. — Reduction  of  Inflamed  Intestine. 

Br  rectal  hernia  (G-er.,  Mastdarmbruch  ;  Gr.,  Archocele,  He- 
drocele)  is  understood  a  hernial  protrusion  of  the  pelvic  or  ab- 
dominal contents  which  has  a  pouch  of  the  rectal  wall  for  a  sac. 

The  sac  of  such  a  hernia  is  generally  composed  of  all  of  the 
layers  of  the  rectum,  including  the  peritoneum.  The  protrusion 
may  be  from  one  side  of  the  wairinto  the  cavity  of  the  bowel 
where  it  is  concealed,  constituting  what  is  known  as  an  internal 
rectal  hernia,  or  one  which  has  not  passed  out  of  the  anus ;  or 
it  may  pass  the  sphincter  and  form  an  external  hernia,  the  sac 
of  which  is  simply  an  extensive  prolapsus  of  the  second  variety 
containing  peritoneum,  as  shown  in  Fig.  59.  Under  its  proper 
title  of  archocele,  or  rectal  hernia,  this  affection  is  seldom  found 
described,  and  this  fact  might  make  it  appear  to  be  rarer  than 
it  really  is.  The  external  variety  of  it,  however,  which  occurs 
as  a  complication  of  extensive  prolapsus,  is  not  particularly 
uncommon,  and  will  often  be  found  referred  to  in  medical  liter- 
ature under  the  head  of  "prolapsus  containing  loops  of  small  in- 
testine." Such  reference  is  generally  limited  to  a  casual  mention 
of  the  possibility  of  the  condition,  and  the  condition  itself  has 
seldom  (never  in  English)  been  described  with  any  approach  to 
completeness. 

Allingham,1  for  instance,  says  under  the  head  of  procidentia 

1  Philadelphia  edition  of  1882,  p.  88. 


RECTAL    HERNIA.  183 

recti :  x(  I  have  had  in  my  own  practice  many  cases  of  prociden- 
tia, in  which  there  was  a  hernial  sac  in  the  protrusion,  and  in 
all  it  was  situated  anteriorly,  as  from  the  anatomy  of  the  part, 
of  course,  it  must  be  ;  you  could  return  the  intestine  out  of  the 
sac,  and  it  went  back  with  a  gurgling  noise.  Directly  the  bowel 
is  protruded  you  can  tell  that  there  is  a  hernia  also  present  by 
the  opening  of  the  gut  being  turned  toward  the  sacrum  ;  when 
the  hernia  is  reduced  the  orifice  is  immediately  restored  to  its 
normal  position  in  the  axis  of  the  bowel.  I  have  seen  several 
similar  cases  in  the  practice  of  my  colleagues  at  St.  Mark's ;  the 
condition  is,  therefore,  not  very  uncommon,  but  I  have  never 
found  it  in  children." 

In  the  course  of  the  following  pages  I  shall  be  forced  to  dif- 
fer from  Allingham  in  his  statement  that  such  a  hernia  must  of 
course  be  in  the  anterior  portion  of  the  prolapsus ;  and,  as  a 
matter  of  fact,  quite  a  large  number  of  all  the  reported  cases 
have  occurred  in  children,  in  whom  its  most  frequent  exciting 
cause,  prolapsus,  is  so  common. 

Van  Buren  '  says,  also  under  the  head  of  prolapsus  :  "I  am 
especially  anxious  to  impress  you  with  the  fact  that  there  is 
always  more  or  less  of  the  peritoneal  sac  carried  down  with  the 
bowel,  and  necessarily  present  in  the  tumor.  I  have  reliable 
information  of  a  case  in  which  the  removal  of  a  '  complete  pro- 
lapse,' of  long  standing,  in  a  child,  was  quite  recently  undertaken 
by  a  hospital  surgeon  of  mature  years.  The  protest  of  a  junior 
colleague  led  the  operator  to  pass  some  deep  sutures,  in  defer- 
ence to  a  fear  expressed  as  to  the  probability  of  intestinal  pro- 
trusion, but  he  was  confident  that  the  tumor  consisted  of 
mucous  membrane  alone,  and  proceeded  to  remove  it.  Not- 
withstanding the  deep  sutures,  protrusion  of  several  coils  of 
small  intestine  did  occur,  and  the  child  died,  in  collapse,  within 
twenty-four  hours." 

Molliere 2  also  refers  to  the  subject  under  the  same  head, 
quoting  Cruveilhier,  Allingham,  and  Uhde,  and  giving  the  case 
of  Roche  in  full  in  a  foot-note.  He  merely  says,  "  if  the  exist- 
ence of  the  condition  is  therefore  demonstrated,  its  history  still 
remains  entirely  to  be  written."  Esmarch  3  refers  to  the  sub- 
ject, but  adds  little  to  it ;  and  generally,  when  it  is  mentioned 
by  the  standard  writers,  it  receives  but  a  passing  notice. 


1  Edition  of  1881,  p.  60.  *  Op.  cit.,  p.  236.         s  Pitha  u.  Billroth,  p.  154. 


184  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Two  articles  have  recently  appeared,  however,  one  by 
Quenu1  and  the  other  by  Englisch,2  which  cover  the  ground 
more  satisfactorily.  These  authors  have  considered  the  subject 
from  different  standpoints,  the  one  writing  upon  "Spontaneous 
Rupture  of  the  Rectum,-'  and  the  other  upon  "Rectal  Her- 
nia," and  have  made  a  careful  collection  of  cases  coming  under 
each  head.  Since  it  is  a  fact  that  spontaneous  rupture  is  gen- 
erally due  to  a  previously  existing  hernia,  Quenu' s  cases  have 
been  included  in  the  following  list,  the  whole  having  been  veri- 
fied as  far  as  possible,  and  some  others  added. 

Case.3 — The  patient  was  a  child  one  year  and  four  weeks 
old,  pale,  bu  t  well  developed,  who  had  frequently  suffered  from 
prolapsus.  Examination  showed  a  tumor  at  the  anus,  50  ctm. 
long,  which  plainly  contained  coils  of  intestine  and  reached  far 
out  upon  the  buttock.  Four  distinct  rolls  were  distinguishable. 
The  outer  surface  of  the  prolapsus  was  reddened,  moist,  and 
shiny,  and  there  was  no  furrow  at  the  anus.  There  was  fever 
and  undoubted  collapse,  and  reposition  was  impossible,  though 
a  large  amount  of  air  and  serous  fluid  were  evacuated  by  punc- 
ture. The  proposed  operation — division  of  the  prolapsus  longi- 
tudinally, reposition  of  the  protruded  intestine,  cutting  off  the 
prolapsus,  and  closure  of  the  wound  with  sutures — was  there- 
fore abandoned.  On  the  evening  of  the  same  day  gangrenous 
spots  appeared  on  the  protrusion,  and  the  child  died  at  one 
o'clock  at  night. 

Autopsy. — Rectum  protruding,  and  the  anterior  portion  of 
the  swelling  filled  with  the  ileum,  which  had  also  displaced  the 
neighboring  small  intestine  and  the  transverse  and  descending 
colon.  The  anus  was  very  wide.  The  contents  of  the  hernia 
consisted  of  at  least  a  third  portion  of  the  ileum  and  the  sig- 
moid flexure.  The  hernial  sac  and  abdominal  contents  were 
inflamed. 

Case.4 — The  patient  was  an  emaciated  female  child,  twenty 
weeks  old,  with  severe  diarrhoea,  and  a  prolapsus  which  rapidly 
increased  to  the  size  of  a  "sausage,"  and  had  the  appearance 
of  a  loop  of  intestine  with  the  concavity  turned  downward. 

1  Des  Ruptures  spontam'-es  du  Rectum  :  Rev.  de  Chir.,  March  10,  1882. 

2  Ueber  den  Mastdarrabrueh  :  Med.  Jahr.,  II.  heft,  1882. 

3  Uhde  :  Langenbeck's  Archiv.  fur  klin.  Chirurgie,  1867.     Bd.  9,  S.  1. 

4  Brurm  :  Beobachtungon  und  Mittheilungen  aus  der  Praxis  2.  Mastdarmbruch, 
Casper's  Wochenschrifte  fur  die  gesammte  Heilkunde  Jahrg.,  1833.  Bd.  2,  No.  40, 
S.  934. 


RECTAL    HERNIA.  185 

Reposition  was  impossible  and  death  followed  from,  rapid  ex- 
haustion in  ten  or  fifteen  hours. 

Autopsy. — The  prolapse  was  not  reducible  and  a  longitudinal 
incision  allowed  several  loops  of  the  ileum,  the  greater  part  of 
which  was  in  the  pelvis,  to  protrude.  The  uterus  was  so  drawn 
into  the  inverted  rectum  that  it  could  only  be  pulled  out  with 
difficulty.  The  wall  of  the  rectum  was  purse-shaped,  inverted, 
and  formed  the  hernial  sac.  The  intestines  were  empty  and 
inflamed  ;  the  other  organs  normal.  Brunn  held  that  the 
strangulation,  though  possibly  due  to  the  sphincter,  was  more 
probably  due  to  the  levator  ani. 

Case.1 — This  patient  was  a  girl,  seven  years  old,  so  thoroughly 
scrofulous  and  rachitic  as  to  appear  like  a  child  one  year  of  age. 
On  November  12,  1821,  a  prolapsus  began  which  in  three  days 
increased  to  the  length  of  the  finger,  was  8"  long,  3"  thick,  and 
had  a  blackish  appearance.  Simultaneously  vomiting  began  with 
fluid  and  painful  passages.  Further  examination  showed  widen- 
ing of  the  external  sphincter,  difficulty  in  replacing  the  prolap- 
sus, swelling  of  the  protruded  rectum,  and  on  that  part  of  the 
prolapse  which  had  laid  upon  the  bed,  gangrenous  spots.  After 
a  number  of  trials  reposition  was  accomplished,  the  contraction 
of  the  sphincter  not  being  the  cause  of  the  difficulty.  The 
reposition  was  made  in  this  way.  The  assistant  took  in  his 
hands,  one  above  the  other,  the  protruded  intestine.  Pockels 
introduced  his  index  finger  into  the  intestine,  and  by  means  of 
the  thumb  pushed  it  back.  During  the  strong  downward 
pressure  of  the  child,  the  finger  was  held  quietly  in  the  in- 
testine. While  the  thumb  rolled  in  the  edge  of  the  protrusion, 
the  index  finger  pushed  the  part  up  over  the  sphincter. 

During  the  reposition  the  examination  with  the  finger 
showed  a  very  much  contracted  pelvis.  The  prolapsus  was 
held  up  by  a  T-bandage.  Afterward  when  prolapse  occurred 
it  was  always  easily  reduced.  On  December  9th  the  patient 
died  from  exhaustion. 

Autopsy. — Intestines  in  pelvis  normal,  with  no  signs  of  in- 
flammation. The  transverse  colon  was  drawn  into  the  inverted 
rectum  and  the  left  ovary  was  within  the  grasp  of  the  sphincter. 
The  wall  of  the  rectum  was  completely  perforated  at  one  point 


1  Pockels :  Catalog  des  collegium  Anat.  chirurg.  Braunschweig,  1854 ;  also  Uhde, 
loc.  cit. ,  S.  13. 


186  DISEASES    OF   THE    RECTUM    AND    ANUS. 

so  that  a  bougie  could  be  introduced  through  the  opening  into 
the  abdominal  cavity. 

Case.1 — The  patient  was  a  woman  seventy-two  years  old, 
who  in  the  interval  between  her  twenty-third  and  thirty-fourth 
years  had  six  confinements  without  difficulty.  The  last  one 
caused  a  rupture  of  the  perineum  which  completely  healed. 
Shortly  after  this  she  began  to  suffer  from  prolapsus,  which  was 
easily  reducible  by  merely  assuming  the  horizontal  position. 
A  slight  prolapse  occurred  after  each  stool.  A  few  months'  stay 
in  hospital,  with  the  use  of  cold  baths  and  injections,  resulted  in 
a  decided  improvement,  and  at  the  time  of  reporting  the  case 
the  patient  had  returned  for  a  second  visit.  She  was  poorly 
nourished,  and  showed  when  standing  and  after  pressure  a  pro- 
lapsus 9  ctm.  long,  pear-shaped,  27  ctm.  in  circumference,  and 
30  ctm.  in  the  largest  part.  A  groove  li  ctm.  deep  surrounded 
the  tumor,  and  there  was  an  opening  2  ctm.  long  at  the  highest 
point.  The  tumor  was  vaulted  on  the  anterior  surface  so  that  it 
measured  16  ctm.  from  the  edge  of  the  skin,  while  the  measure- 
ment on  the  posterior  surface  was  only  7  ctm.  The  ring  sur- 
rounding the  opening  in  the  tumor  exhibited  a  row  of  longitudi- 
nal folds  diverging  into  a  wide  tract  upon  the  outer  surface. 
If  the  finger  was  pushed  through  the  opening  into  the  rectum, 
it  came  in  contact  posteriorly  with  the  enclosed  and  enclosing 
portions  of  the  rectal  wall,  and  further  on,  against  the  point  of 
the  coccj7x.  The  further  the  examination  was  carried  beyond 
the  point  of  the  coccyx  the  more  the  layers  separated  from 
each  other. 

The  outer  surface  of  the  tumor  was  covered  with  reddened 
and  sometimes  excoriated  spots.  The  wall  was  about  equal  in 
thickness  at  all  points.  The  outer  surface  seemed  about 
equally  stretched  in  the  middle  portion,  but  somewhat  dis- 
tended at  the  higher  points,  and  under  strong  pressure  bulg- 
ings  showed  themselves.  The  consistence  was  soft,  and  such  as 
to  allow  a  decrease  in  size  by  pressure.  The  percussion  sound 
was  tympanitic  in  front.  A  vaginal  examination  showed  the 
posterior  wall  to  be  unevenly  stretched  backward  and  down- 
ward, forming  a  shallow  depression  ;  but  the  other  parts  had 
suffered  no  change.  If  an  attempt  was  made  to  decrease  the 
size  of  the  tumor  by  pressure  the  twisting  and  gurgling  of  the 

1  Englisch  :  Med.  Jahr.,  1882.     II.  Heft. 


RECTAL    HERNIA.  187 

intestine  contained  in  it  could  be  felt  both  in  front  and  behind, 
especially  in  front.  If  the  intestine  was  completely  reduced 
there  remained  a  slack  prolapsed  sac  5  ctm.  long,  which  could 
also  be  reduced.  When  this  was  done  the  sphincter  was  seen 
to  be  dilated  so  that  it  admitted  three  fingers,  and  the  lower 
part  of  the  rectum  was  also  stretched.  When  the  hernia  was 
not  protruded  the  abdomen  was  soft  and  evenly  distended ; 
but  when  the  tumor  was  in  the  condition  first  described,  the 
vaulting  of  the  abdomen  disappeared,  especially  in  its  lower 
part,  the  umbilicus  was  depressed  about  1  ctm.,  and  longitud- 
inal folds  appeared  in  the  lower  abdominal  region  which  di- 
verged from  the  umbilicus  toward  the  symphysis.  The  curv- 
ing of  the  sacrum  and  coccyx  was  very  slight,  and  both  extended 
widely  backward. 

The  difficulty  of  which  the  patient  complained  was  very 
trifling,  being  only  that  which  naturally  arose  from  the  presence 
of  the  tumor  in  standing  and  walking,  and  the  frequent  burn- 
ing sensation  which  resulted  from  excoriation  of  the  mucous 
membrane.  There  was  no  pain  on  defecation  except  during 
costiveness,  and  only  occasionally  any  pain  in  the  abdomen. 

Case.1 — The  patient  was  a  middle-aged  woman,  who  was 
suddenly  seized,  in  the  middle  of  the  night,  with  nausea  and 
pain  in  the  abdomen.  After  making  violent  efforts  at  vomiting 
she  discovered  something  unusual,  which  made  her  think  she 
was  about  to  have  a  miscarriage,  and  caused  her  to  send  for  a 
midwife.  For  a  time  she  was  attended  by  a  physician  who  dis- 
covered a  large  portion  of  the  small  intestine  outside  of  the  anus, 
and  who  finally  sent  her  to  Saint  George' s  Hospital.  At  this 
time  not  less  than  two  yards  of  small  intestine,  with  its  mesen- 
tery, was  protruding  from  the  anus.  The  whole  mass  was 
greatly  inflamed,  and  the  loops  were  distended  with  gas  and 
faeces.  At  two  inches  from  the  anus  a  transverse  rent  on  the 
anterior  wall  of  the  rectum  could  be  felt  by  the  finger.  At- 
tempts at  reduction  only  succeeded  in  replacing  three-fourths 
of  the  hernial  mass,  and  most  of  this  was  pressed  up  into  the 
rectum  instead  of  into  the  peritoneal  cavity,  and  remained  there 
only  as  long  as  the  pressure  was  maintained. 

Under  these  circumstances  Brodie  made  an  incision  in  the 
linea  alba  below  the  umbilicus,  and  by  introducing  the  finger 

1  Brodie  :  London  Medical  and  Physical  Journal,  1827,  vol.  lvii. 


188  DISEASES    OF   THE    RECTUM    AND    ANUS. 

effected  the  reduction  of  the  hernia,  closing  the  abdominal 
wound  with  sutures.  After  the  operation  the  pulse  was 
scarcely  perceptible,  the  extremities  were  cold,  and  all  nour- 
ishment was  vomited  immediately.  The  patient  died  in  col- 
lapse eight  hours  after  the  operation. 

Autopsy. — The  peritoneum  was  found  much  inflamed  and 
covered  in  some  places  with  coagulated  lymph  ;  and  there  was 
a  transverse  wound  in  the  anterior  wall  of  the  rectum  with  no 
trace  of  ulceration  in  the  neighborhood.  It  was  concluded  that 
in  this  case  the  hernia  was  the  result  of  an  accidental  rupture, 
and  no  mention  is  made  whether  the  patient  had  or  had  not 
previously  suffered  from  prolapsus. 

Case.1 — The  patient,  a  male,  aged  forty -five  years,  entered 
the  Hotel  Dieu  October  21,  1879,  in  a  state  of  collapse,  but  with 
intellect  unaffected.  On  uncovering  him  an  enormous  mass  of 
intestinal  loops  was  seen  protruding  from  the  anus  together  with 
their  mesenteric  attachment.  In  spite  of  his  prostration  he  was 
able  to  give  the  following  history  :  He  was  well  in  the  morning 
and  went  about  his  usual  work.  At  seven  o'clock  he  had  a  de- 
sire to  go  to  stool,  and  during  the  efforts  at  defecation  he  experi- 
enced pain  in  the  abdomen,  became  sick,  passed  a  large  quan- 
tity of  blood,  and  finally  the  intestine.  A  doctor  was  called, 
and  after  an  attempt  at  reduction  the  man  was  sent  to  the  hos- 
pital. An  attempt  was  made  to  discover  if  he  had  suffered  from 
any  previous  rectal  disease,  and  he  affirmed  that  his  health  had 
been  good,  that  there  had  been  no  emaciation,  and  no  previous 
pain  in  the  abdomen  ;  but  during  the  past  two  months  he  had 
occasionally  passed  blood  at  stool,  and  two  years  before  some- 
thing came  down  by  the  anus  which  he  was  able  to  reduce  him- 
self without  difficulty.  He  imagined  that  a  similar  accident  had 
happened  again.  Pains  were  taken  to  find  out  from  him  whether 
he  had  had  a  fall,  or  whether  he  had  not  introduced  something 
into  the  rectum,  but  he  always  answered  in  the  negative. 

The  suffering  did  not  appear  to  be  very  intense  ;  the  abdo- 
men was  supple,  flat,  and  only  slightly  sensitive  ;  at  every  mo- 
ment the  patient,  in  spite  of  advice,  made  an  effort  as  if  in  defe- 
cation. The  intestinal  loops  which  protruded  from  the  anus 
were  piled  up  one  upon  the  other,  and  formed  a  mass  the  size  of 
a  man's  head.     An  approximate  measurement  gave  two  metres 

1  Qucnu  :  Revue  de  Chir.,  November  3,  1882. 


EECTAL    HERNIA.  189 

as  the  length  of  protruded  small  intestine,  the  serous  surface  of 
which  forbade  any  idea  of  an  invagination.  The  loops  were 
cold  and  inert,  moderately  distended  with  gas,  and  without  any 
vermicular  movement.  With  regard  to  color,  two  different  parts 
of  the  mass  could  be  distinguished :  one  violet,  ecchymosed, 
resting  upon  the  clothes  ;  the  other  simply  congested  and  ap- 
pearing to  have  come  out  more  recently.  The  mesentery  was 
infiltrated  with  blood,  and  there  was  blood  upon  the  patient's 
shirt.  The  anus  was  large  and  the  sphincter  relaxed.  There 
was  no  trace  of  rupture  within  reach  of  the  finger. 

The  reduction  was  commenced  with  those  loops  which  ap- 
peared to  have  escaped  last  and  were  the  least  changed,  and  after 
twenty-live  minutes  it  was  accomplished.  Then  the  whole  hand 
was  passed  into  the  rectum  and  the  rupture  was  found  high 
upon  the  anterior  wall.  'A  single  loop  remained  in  the  rectum, 
and  its  reduction  was  not  insisted  upon,  in  the  hope  that  the 
vermicular  movement  of  the  bowel  might  suffice  to  reduce  it. 
A  large  tampon  of  cotton  and  a  T-bandage  were  applied.  The 
patient  was  relieved  by  the  reduction,  but  did  not  rally,  and 
died  two  hours  later  without  having  vomited,  and  with  the  ab- 
domen still  supple  and  not  distended. 

Autopsy. — The  loops  which  had  been  replaced  could  easily 
be  distinguished  by  their  color,  and  by  the  bloody  infiltration 
of  their  walls.  The  large  intestine  was  in  its  place  and  the 
loop  which  had  been  left  in  the  rectum  had  returned  to  the 
peritoneal  cavity.  The  abdominal  cavity  contained  one  litre 
and  a  half  of  uncoagulated  blood.  On  the  anterior  surface  of 
the  upper  portion,  of  the  rectum  there  was  a  longitudinal 
wound  through  which  the  mucous  membrane  could  be  distin- 
guished. The  rectum  was  empty  and  flat.  The  bladder  was 
empty,  and  the  lower  end  of  the  rupture  was  eight  centimetres 
from  the  recto-vesical  cul-de-sac.  The  rupture  was  to  the  left  of 
the  median  line,  and  involved  the  coats  of  the  rectum  to  differ- 
ent degrees  ;  the  wound  in  the  mucous  membrane  measuring  4.3 
ctm.,  and  that  in. the  peritoneum  10  ctm.  Between  these  two  the 
layers  of  the  intestine  had  been  dissected  up  by  blood,  but  the 
separation  had  especially  affected  the  mucous  membrane,  which 
was  separated  from  the  other  layers  to  the  extent  of  3.4  ctm. 
above,  2.3  ctm.  below,  and  from  1  to  2  ctm.  laterally.  The  layer 
of  circular  fibres  had  been  separated  in  some  places  in  two  planes, 
one  of  which  remained  adherent  to  the  mucous  membrane.     All 


100  DISEASES    OF   THE    FwECTUM    AND    ANUS. 

the  right  half  of  the  rectum,  corresponding  in  extent  to  the  rup- 
ture, presented  a  series  of  soft  black  protuberances  due  to  an 
effusion  of  blood  beneath  the  peritoneum.  The  meso-rectum 
showed  no  bloody  infiltration.  The  veins  of  the  rectal  wall  ap- 
peared more  developed  than  normal  ;  there  were  traces  of  old 
haemorrhoids  at  the  anus  ;  and  the  rectal  mucous  membrane 
was  absolutely  healthy  and  without  a  trace  of  ulceration  to  the 
naked  eye  ;  but  under  the  microscope  it  showed  marked  signs  of 
severe  inflammation,  similar  to  those  seen  in  the  stomachs  of 
tuberculous  persons  who  have  died  with  symptoms  of  gastritis. 

Case.1 — The  patient,  a  woman  aged  seventy- two  years,  had 
suffered  for  several  years  from  an  easily  reducible  prolapse. 
After  a  stool  without  unusual  straining  she  observed,  on  return- 
ing the  prolapse,  the  sudden  appearance  of  intestine  through 
the  anus,  attended  with  great  pain  in  the  region  of  the  stomach. 
As  a  result  of  straining  the  hernia  rapidly  increased,  and  Adel- 
mann  found  five  ells  of  small  intestine  prolapsed,  the  mass 
reaching  the  ground,  and  soiled  with  dirt  and  urine.  The  pro- 
trusion was  dark  colored  and  the  mesentery  was  marked  with 
dark  spots.  It  lay  in  six  loops,  the  lowest  being  longest  and 
the  shortest  uppermost.  The  sphincter  was  relaxed.  The 
rupture  was  on  the  right  side  of  the  rectal  wall  2i"  from  the 
anus,  running  from  behind  forward  and  allowing  only  the  front 
part  of  the  sharp  edge  to  be  plainly  seen.     Its  length  was  2£". 

Reposition  was  undertaken  in  the  knee-elbow  position  and 
proceeded  with  comparative  ease  till  the  pelvis  was  full,  after 
which  no  more  could  be  replaced,  the  abdominal  cavity  not 
having  been  accustomed  for  a  long  time  to  the  presence  of  the 
intestine.  A  laparotomy  was  therefore  necessary.  An  incision 
was  made  at  the  level  of  the  umbilicus,  3"  from  the  median  line 
to  the  right,  at  the  outer  edge  of  the  rectus,  4"  long,  extending 
downward  to  within  three  fingers'  breadth  of  the  pubes ;  per- 
mit ting  the  entrance  of  the  hand  into  the  abdomen.  Bypas- 
sing the  hand  along  the  mesentery  to  the  rent  the  intestine 
could  be  drawn  back  with  the  help  of  an  assistant.  In  this 
way  1£  ell  was  returned,  and  the  rest  was  punctured  with  a 
broad  needle  to  allow  the  escape  of  gas  and  contents.  The  dis- 
charge through  the  prolapsed  mucous  membrane  was  not  at  all 
free,  and  it  was  assisted  by  introducing  a  sound  through  the 

1  Adelmann  :  Journal  fur  Chirurgie  und  Augenheilkunde,  1845. 


RECTAL    HERNIA.  191 

punctures.  After  removing  the  hand  from  the  abdomen,  the 
reposition  could  be  carried  no  further,  and  a  loop  of  intestine 
also  appeared  in  the  abdominal  wound.  After  placing  the 
patient  on  the  left  side  the  rectum  was  exposed  and  the  rent, 
which  had  sharp  edges  through  its  whole  extent,  was  united 
with  seven  sutures.  The  sutures  in  the  middle  of  the  wound 
were  placed  at  some  distance  from  each  other,  to  allow  of  dis- 
charge from  the  pelvic  cavity.  Toward  the  end  of  the  suturing, 
the  contractions  of  the  levator  ani  could  be  distinctly  appreci- 
ated. After  replacing  the  intestinal  loop  the  abdominal  incision 
was  also  closed.  Three  fluid  passages  occurred  immediately 
after  the  operation  was  completed  ;  and  the  patient  died  ten 
hours  later,  and  seventeen  hours  after  the  accident. 

Autopsy. — Six  or  eight  ounces  of  sero-sanguinolent  fluid  in 
the  peritoneal  cavity  without  trace  of  coagulation.  No  peri- 
tonitis in  the  neighborhood  of  the  rupture.  The  mucous  mem- 
brane was  inflamed  and  congested,  and  in  some  places  eroded, 
and  there  were  red  spots  on  the  visceral  layer  of  peritoneum 
formed  by  an  effusion  of  blood  between  the  layers  of  intestine. 
Especial  attention  is  called  to  the  fact  that  the  nail  of  the  index 
ringer  on  the  patient's  right  hand  was  sharp,  and  it  was  thought 
that  in  the  efforts  at  replacement  this  might  have  lacerated  the 
bowel,  and  thus  caused  the  rupture  of  the  hernial  sac. 

Case.1 — The  patient,  a  woman  fifty  years  of  age,  had  suffered 
for  many  years  from  severe  prolapsus.  Being  engaged  in  a  fight 
with  another  woman  she  was  thrown  upon  her  back,  and  the 
prolapsus  was  injured  by  the  feet  in  the  struggle.  Immediately 
after  she  wished  to  go  to  stool,  and  after  some  straining  she 
passed  a  considerable  quantity  of  blood  and  some  loops  of  small 
intestine.  The  hernia,  which  was  at  first  the  size  of  the  fist, 
constantly  increased  by  the  straining  of  the  patient,  and  she 
died  in  collapse  twelve  hours  after  the  accident. 

Autopsy. — The  intestine  was  found  inflamed  ;  all  of  the 
larger  bowel  was  contained  in  the  pelvis,  and  the  stomach  was 
forced  downward  into  a  vertical  position.  The  prolapsed  bowel 
was  12'  10"  long,  and  included  the  whole  ileum  beginning  2" 
from  the  ileo-csecal  valve  ;  and  also  a  part  of  the  jejunum.  The 
rupture  was  on  the  posterior  wall  1"  from  the  anus,  and  four 


1  Pyl :  Pyl's  Aufsatze  und  Beobachtungen,  zweite  abtheilung,  p.  133;  or  Adelmann, 
loc.  cit. 


192  DISEASES    OF    THE    KECTUM    AND    ANUS. 

fingers'    breadth    long.     The  abdomen  also    contained    extra- 
vasated  faeces. 

Case.  ' — The  case  was  that  of  a  woman,  aged  forty-six  years, 
who  about  twelve  years  before,  a  short  time  after  a  difficult 
labor,  had  begun  to  suffer  from  prolapse  which  came  down 
daily  at  the  time  of  defecation,  and  was  easily  reducible.  She 
was  seen  by  the  doctor  at  a  time  when  the  tumor  had  been  down 
nearly  twenty-four  hours,  and  had  resisted  all  the  efforts  of 
herself  and  female  friends  at  replacement.  She  had  passed  a 
restless  night  and  was  much  fatigued  by  her  journey  in  an  old 
cart,  but  had  experienced  no  bad  symptoms  referable  to  the 
stomach  or  bowels.  The  doctor  found  at  the  anus  a  tumor 
larger  than  the  fist,  round,  red,  and  covered  with  bloody  mucus. 

The  prolapse  was  directly  continuous  with  the  margin  of  the 
anus,  in  such  a  manner  as  to  render  the  introduction  of  a  sound 
between  them  impossible.  At  the  extremity  of  the  tumor  there 
was  a  rounded  aperture  which  admitted  the  finger  without  ob- 
stacle. To  accomplish  the  reduction  the  woman  was  placed  on 
the  bed  with  the  thighs  separated  ;  the  tumor  was  seized  in  the 
palms  of  the  two  hands  and  the  ends  of  the  fingers,  and  a  gen- 
tle circular  compression  was  exercised  in  order  to  diminish  its 
volume  and  cause  it  to  go  up  by  an  operation  similar  to  the 
taxis.  The  resistance  being  great,  a  few  moments  were  allowed 
for  rest,  and  after  a  quarter  of  an  hour  the  same  manoeuvre 
was  repeated  after  having  enveloped  the  tumor  in  a  cold  cloth. 
"After  a  few  moments  I  felt,"  says  the  narrator,  "during  a 
violent  effort  of  the  patient,  the  tumor  distend  under  my  fin- 
gers, and  at  the  same  time  I  heard  a  noise  similar  to  that  made 
by  tearing  parchment.  At  the  same  time  the  tumor  suddenty 
disappeared  of  itself,  and  syncope,  nausea,  and  a  marked  change 
in  the  expression  of  the  face  supervened. 

"  When  the  patient  came  to  herself  she  complained  of  severe 
colic.  I  then  found  outside  of  the  anus  a  loop  of  intestine 
which  I  easily  replaced,  and  on  introducing  the  finger  into  the 
rectum  I  recognized  at  a  considerable  height  an  irregular  longi- 
tudinal rent,  the  extent  of  which  I  was  unable  to  determine.  I 
placed  a  tampon  of  lint  over  the  anus  and  kept  it  in  place  with 
a  T-bandage  and  compress.  I  sent  the  patient  to  her  home, 
ordering  that  nothing  be  disarranged.     As  the  case  was  very 

1  Eoche  :  Revue  Mud.-Chirurg.,  1853. 


RECTAL    HERNIA.  193 

serious,  I  requested  a  neighboring  confrere  to  come  and  aid  me 
with  his  advice.  At  our  arrival,  six  hours  after  the  accident,  I 
found  the  patient  sitting  by  the  corner  of  the  fire,  without  the 
dressings.  Between  the  separated  thighs  were  exposed,  in  the 
midst  of  the  ashes,  the  large  and  a  considerable  part  of  the 
small  intestines,  distended  with  gas,  cold,  and  in  several  spots 
livid.  The  face  was  Hippocratic,  the  pulse  thready  and  much 
accelerated,  the  voice  feeble  ;  and  to  this  was  joined  colic  and 
continual  vomiting.  After  having  placed  the  woman  in  bed 
and  raised  the  intestines,  the  mass  was  replaced  within  the 
body,  the  former  dressing  was  applied,  and  the  woman  died  in 
a  few  hours." 

Case.1 — A  woman,  thirty  years  of  age,  wishing  to  lift  a  heavy 
vase,  and  stooping  over  to  accomplish  it,  suddenly  caused  a 
very  considerable  intestinal  hernia  to  appear  through  the  anus 
which  could  not  be  reduced  even  by  the  introduction  of  the 
whole  hand  within  the  rectum.  Stein  thought  he  might  be  able 
to  effect  the  reduction  by  raising  the  pelvis,  but  this  manoeuvre 
failing,  he  cut  the  intestine  to  empty  it  of  its  contents,  hoping 
at  the  same  time  to  establish  an  artificial  anus.  Death  followed 
on  the  sixth  day  from  general  peritonitis. 

Autopsy. — Rupture  10,"  long  in  the  anterior  wall  of  the  rec- 
tum, through  which  several  feet  of  the  small  intestine  and  two 
inches  of  the  caecum  had  protruded. 

Case.2 — In  this  case,  which  is  reported  by  Fiedler  from  the 
practice  of  Ohle,  and  copied  by  Ashhurst,  the  patient,  a  man, 
gave  a  past  history  of  haemorrhoids,  obstinate  constipation, 
bloody  stools,  difficulty  in  micturition,  and,  finally,  the  develop- 
ment of  a  tumor  filling  the  anus.  Without  known  cause  he  was 
attacked  with  fever,  vomiting,  and  great  pain  in  the  abdomen. 
An  examination  revealed  the  presence  of  a  swelling  at  the  anus, 
3"  in  diameter,  and  this  was  incised  on  the  diagnosis  of  an  at- 
tending physician.  It  contained  one  of  the  appendices  epi- 
ploicse  and  a  piece  of  small  intestine.  To  replace  this  Ohle  made 
an  incision  on  the  left  side  from  the  tip  of  the  tenth  and  eleventh 
costal  cartilages  to  the  anterior  superior  spine,  5£"  long,  parallel 
to  the  linea  alba  and  3£"  from  it.  Through  this  the  transverse 
colon  was  drawn  outward,  the  intussusception  reached,  and  the 

1  Stein  :  Pitha  und  Billroth  Chirurgie. 

'-  Ohle.     Fiedler  :   Magazin  der  gesammten  Heilkunde  von  Rust,  Bd.  2,  S.   253, 
1817;  Ashhurst:  Amer.  Jour,  of  the  Med.  Sciences,  1874,  vol.  ii.,  p.  48. 
13 


194  DISEASES    OF   THE    RECTUM    AND    ANUS. 

small  intestine  drawn  out  of  the  wound  in  the 'rectum,  while  an 
assistant  made  pressure  from  without.  The  patient  died  of  peri- 
tonitis. 

Case.1 — The  patient  was  an  old  woman  who  had  borne  three 
children  without  difficulty.  Following  the  second  birth  there 
was  a  prolapse  of  the  vagina,  and  after  the  third  a  prolapse 
of  the  rectum  accompanied  by  alternate  diarrhoea  and  constipa- 
tion. For  the  last  ten  years  the  prolapse  had  been  increasing 
in  size  and  had  remained  out  of  the  body  when  the  patient  was 
in  the  horizontal  position.  At  the  same  time  inflammation  had 
occurred  so  that  she  was  obliged  to  take  to  her  bed.  This  in- 
flammation suddenly  became  increased,  the  patient  had  a  chill 
with  severe  colicky  pain  in  the  lower  pelvis  radiating  from  the 
rectum  and  the  genitals,  and  high  fever.  Later  there  was  vom- 
iting, and  after  eight  days  a  rupture  of  the  weakened  hernial 
sac  and  death  from  peritonitis. 

Autopsy  confirmed  the  diagnosis  of  rectal  hernia. 

Case. — The  same  author  reports  another  case,  in  a  woman 
forty  years  of  age,  who  had  never  borne  children.  In  her  child- 
hood she  had  suffered  from  a  prolapsus  which,  however,  had 
always  been  reducible.  This  again  developed  later,  and  was 
only  reducible  with  difficulty  and  undoubtedly  contained  intes- 
tine. 

Case.2 — In  1835  a  feeble  child,  one  year  old,  was  brought  for 
treatment  who  had  a  prolapse  3"  long  and  of  unusual  thickness. 
The  examination  showed  an  undoubted  interval  between  the  two 
layers  of  the  inverted  rectum  in  front,  and  intestine  between 
them.  Reposition  was  impossible,  and  the  weakness  of  the 
patient  rendered  operation  out  of  the  question.  The  child  died 
on  the  same  day.     No  autopsy. 

Case.' — This  surgeon  observed  in  1844,  in  a  child  two  years 
of  age  who  suffered  with  the  symptoms  of  volvulus,  a  swelling 
in  the  rectum  which  occluded  it  so  completely  that  the  finger 
could  not  be  made  to  pass.  After  death,  which  soon  followed, 
a  large  coil  of  intestine  was  found  in  the  swelling.  No  more  ac- 
curate description  of  the  case  is  given,  but  from  the  author's 
few  words  it  would  seem  to  have  been  one  of  the  class  of  internal 
rectal  hernia?  shown  in  Fig.  4. 

1  Schreger:  Chirurgiscbe  Versuche,  Nurnberg,  1818,  Bd.  2,  p.  186. 

2  Baum  :  See  case  of  Uhde,  loc.  cit. 

*  Dieffenbach  :  Operative  Chirurgie,  Bd.  2,  S.  631,  Leipzig,  1848. 


RECTAL    HERNIA.  195 

Case.1 — This  was  a  case  of  prolapsus  the  size  of  the  fist,  in  a 
woman,  which  evidently  contained  intestine.  After  replacing 
the  hernial  protrusion  the  prolapsus  was  cut  off  with  an  ecra- 
seur,  and  with  it  the  hernial  sac  lying  in  the  anterior  part.  On 
the  day  after  the  operation  both  the  folds  of  peritoneum  became 
loosened  and  a  large  mass  of  small  intestine  appeared.  The 
patient  died  of  peritonitis. 

Case.2 — The  patient,  a  woman  aged  forty-five  years,  had  had 
several  children,  the  last  confinement  being  twenty-two  years  be- 
fore, and  all  having  been  without  difficulty.  Eleven  years  before 
she  felt  a  good  deal  of  uneasiness  about  the  anus  with  difficulty 
in  defecation.  One  morning,  when  getting  out  of  bed,  she  felt  a 
tumor  projecting  from  the  anus.  It  was  about  the  size  of  a 
walnut  and  became  larger  on  exertion.  After  awhile  it  always 
came  down  when  she  went  to  stool,  and  she  could  not  defecate 
without  passing  the  hand  into  the  rectum  and  pushing  the  sub- 
stance aside.  She  had  a  good  deal  of  pain  about  the  umbilicus 
and  was  always  constipated.  During  the  last  ten  months  the 
prolapse  had  increased  till  it  had  reached  the  size  of  a  cocoa- 
nut,  and  was  always  down  when  she  was  at  work,  though  she 
was  comparatively  comfortable  when  in  the  horizontal  position. 

Operation. — It  was  discovered  that  the  anterior  fold  of  the 
protruding  bowel  contained  a  large  globular  body  which  could 
easily  be  encircled  at  the  base  by  the  finger  and  thumb.  On 
passing  the  forefinger  of  one  hand  into  the  vagina  and  that  of 
the  other  hand  into  the  rectum,  their  points  could  easily  be  ap- 
proximated above  the  tumor.  On  rubbing  the  ends  of  the  fin- 
gers together  in  this  position  a  cord  feeling  precisely  like  the 
spermatic  cord  in  the  male,  with  its  vas  deferens,  could  be  felt 
rolling  between  them.  It  was  concluded  that  this  cord  was  the 
Fallopian  tube  and  that  in  all  probability  the  tumor  was  an 
ovarian  cyst. 

An  incision  was  made  on  the  anterior  aspect,  a  small  ovarian 
tumor  was  turned  out,  the  pedicle  was  tied  with  a  strong 
hempen  ligature,  the  tumor  removed,  and  the  wound  closed 
with  the  uninterrupted  suture.  There  was  considerable  bleed- 
ing from  the  wall  of  the  rectum,  requiring  one  or  two  ligatures, 
and  the  prolapsus  was  left  outside  of   the  sphincter.     After 

1  Streubel  :   Handbuch  der  Chirurgie  von  Pitha  und  Billroth,  Bd.  3,  Abth.  2,  S. 
336,  Schmidt,  Hernien. 

2  Stocks  :  British  Medical  Journal,  June  1,  1872,  p.  584. 


196  DISEASES    OF   THE    RECTUM    AND    ANUS. 

healing  of  the  incision  this  could  be  returned  without  pain,  and 
the  patient  made  a  good  recovery. 

Case.1 — As  this  case  seems  to  have  been  beyond  the  reach  of 
both  Quenu  and  Englisch,  both  of  whom  refer  to  it  without 
having  been  able  to  obtain  it ;  and  as  it  is  short  and  very  im- 
portant we  transcribe  it  in  full. 

"  An  Account  of  a  very  RemarTcable  Case  of  a  Boy,  who,  not- 
withstanding that  a  Considerable  Part  of  his  Intestines 
toere  forced  out  by  the  Fall  of  a  Cart  upon  him,  and 
afterward  cut  off,  recovered  and  continued  well.  Read 
June  12,  1755. 

"On  January  3,  1755,  I  was  called  to  John,  the  son  of 
Lancelot  Watts  (a  day  laborer  living  in  Brunsted),  a  servant- 
boy  to  Mr.  Pile,  a  farmer  in  Westwick,  near  North  Walsham, 
Norfolk,  aged  thirteen  years.  He  was  overturned  in  a  cart,  and 
thrown  flat  on  his  face,  with  the  round,  or  edge  of  one  side  of 
the  cart  (bottom  upward)  whilmed  (sic)  across  his  loins,  the 
upper  part  of  the  body  lying  beyond  the  wheel  at  right  angles. 
In  this  helpless  condition  he  continued  some  time,  and  was 
found  with  a  very  large  portion  of  the  intestines  forced  out  at 
the  anus,  with  part  of  the  mesentery  (and  some  loose  pieces  of 
fat  which  I  took  to  be  part  of  the  omentum)  hanging  down 
below  the  hams  double,  like  the  reins  of  a  bridle,  very  much 
distended  and  inflamed.  He  had  a  continual  nausea,  and  vio- 
lent Teachings  to  vomit,  and  threw  up  everything  he  took.  The 
pain  of  the  stomach  and  bowels  was  exquisite,  attended  with 
convulsions ;  his  pulse  low  and  quick ;  and  frequently  he  fell 
into  cold  sweats.  After  using  an  emollient  and  spirituous 
fomentation  I  reduced  the  parts,  though  to  no  purpose  ;  the 
vomiting  immediately  returned,  and  forced  them  out  again. 
Next  day  the  fever  increased,  the  nausea  and  Teachings  to  vomit 
continued,  the  parts  appeared  livid  and  black,  with  all  signs  of 
a  mortification.  On  the  third  day  the  mortification  increasing, 
I  cut  off  the  intestine  with  the  mesentery  close  to  the  anus.  He 
had  had  no  food  from  the  time  of  the  accident,  but  soon  after 
the  operation  there  was  a  very  large  discharge  of  blackish  and 
extremely  offensive  faeces  which  continued  several  days,  lessen- 
ing by  degrees.  He  soon  grew  easy  and  the  nausea  and  vomit- 
ing abated.     I  gave  him   Tinct.   Cort.  Peruv.,    simpl.,  twice  a 

1  Nedbam  :  Philosoph.  Trans.,  vol.  xlix.,  1755,  p.  238. 


RECTAL    HERNIA.  197 

day  ;  and,  as  he  complained  at  times  of  griping  pains,  lie  took 
now  and  then  Tinct.  Rhubarb  vinos.,  and  had  recovered  a  good 
state  of  health.  For  some  time  he  had  six  or  seven,  or  more- 
stools  a  day  ;  at  present  commonly  three  or  four,  all  loose, 
which  come  soon  after  eating  ;  and  frequently  he  is  obliged  to 
hurry  out  to  ease  himself  during  his  meals. 

"  I  have  three  times  lately  tried  if  I  could  discover  a  passage 
through  the  coats  of  the  rectum  with  my  finger,  and  I  think  I 
have  always  felt  an  opening,  just  above  the  sphincter,  toward 
the  spine,  the  circumference  of  which  was  full,  and  protuber- 
ated,  seemingly  as  large  as  my  finger,  the  lower  edge  of  which 
was  harder  than  the  rest ;  he  complained  of  pain  when  I  pressed 
the  upper  part. 

"The  intestine  cut  off  measured  fifty-seven  inches,  by  a 
string  applied  to  the  outer  surface. 

"On  May  7fch,  the  boy  came  walking  from  Brunsted  to 
North  Walsham  (seven  miles),  and  dined  with  me,  was  per- 
fectly well,  and  walked  back  again  that  afternoon. 

"John  Nedham. 
"Witness,  E.  Brooke,  Surgeon. 

"  Nobth  Walsham,  Norfolk, 
"May  28,  1755." 

Case.1 — "The  patient  was  an  elderly  man  who  had  a  pro- 
lapsus as  big  as  a  cocoa-nut  always  coming  down,  and  render- 
ing his  life  a  burden.  He  had  already  been  operated  upon 
twice  by  a  hospital  surgeon,  but  in  vain.  The  patient  was  then 
sent  to  me,  and,  formidable  as  the  case  looked,  I  determined  to 
undertake  it.  I  applied  the  clamp  deeply  in  three  different 
directions.  There  was  a  great  deal  of  bleeding  and  I  had  to  ap- 
ply the  cautery  over  and  over  again  before  I  could  stop  it ;  and 
then,  just  as  I  was  finishing  the  operation,  a  most  untoward 
event  occurred — severe  vomiting,  as  the  result  of  the  anaes- 
thetic, took  place.  The  prolapsus  was  forced  still  further 
down,  and  before  I  and  my  assistants  could  return  the  parts, 
the  violent  action  of  the  abdominal  muscles  was  such  that  the 
weakened  coat  of  the  bowel  gave  way,  and  a  knuckle  of  small 
intestine  actually  protruded  through  the  rent  thus  made.  I 
carefully  returned  this  as  soon  as  the  vomiting  ceased,  and 
anxiously  waited  the  result.     Our  house-surgeon,   Mr.   New- 

1  Henry  Smith  :  Lancet,  March  15,  1880. 


198  DISEASES    OF   THE    KECTUM    AND    ANUS. 

march,  watched  the  patient  with  great  care  and  treated  him 
with  great  skill,  keeping  him  constantly  under  the  influence  of 
opium,  and  locking  up  his  bowels  for  several  days.  The  result 
was  not  a  single  bad  symptom  of  any  kind.  On  the  first  action 
of  the  bowels  there  was  no  protrusion,  nor  afterward,  and  as 
soon  as  the  man  was  fairly  recovered  I  removed  three  longitud- 
inal folds  of  skin  from  the  anus,  so  as  further  to  tighten  the 
parts.  The  man  was  completely  cured.  Now,  the  lesson  this 
case  teaches  is  this — not  to  employ  an  agent  which  could  cause 
vomiting  ;  because,  of  course,  in  such  a  terribly  severe  case  as 
this  it  is  absolutely  necessary  to  clamp  deeply,  and  thus  weaken 
the  bowel.  It  was  a  most  unlooked-for  accident,  not  likely  to 
occur  again ;  in  fact,  it  is  hardly  reasonable  to  expect  to  meet 
with  another  such  a  case  for  operation.  I  have,  however,  been 
called  to  cases  as  bad  or  worse,  but  where  no  operation  could  be 
recommended." 

Anatomy. — To  properly  understand  the  anatomical  forma- 
tion of  a  rectal  hernia  a  knowledge  of  the  structure  and  rela- 
tions of  the  pelvic  diaphragm  is  absolutely  essential.  This  dia- 
phragm, which  forms  an  adequate  support  for  the  pelvic  and 
abdominal  contents  and  completely  closes  the  outlet  of  the 
pelvis,  is  a  funnel-shaped,  musculo-aponeurotic  sheet  stretched 
across  the  pelvis  with  its  apex  pointed  downward.  Through 
the  apex  passes  the  rectum,  to  the  circumference  of  which  the 
diaphragm  is  closely  attached  by  a  commingling  of  muscular 
fibres.  Between  the  rectum  and  the  symphysis  pubis  lies  the 
prostate  which  may  also  be  said  to  help  close  the  mouth  of  the 
funnel  and  to  which  the  diaphragm  is  also  closely  adherent. 

The  pelvic  diaphragm,  which  has  been  diagrammatically  rep- 
resented in  Fig.  65,  is  composed  of  several  layers.  These  may 
be  enumerated  from  above  downward  as  peritoneum,  recto-vesi- 
cal  fascia,  levator  ani  muscle,  and  anal  fascia.  The  peritoneum 
and  its  loose  cellular  attachment  to  the  recto-vesical  and  pelvic 
fascia?  needs  no  particular  description  in  this  connection,  except 
as  the  drawing  happens  to  show  what  Richet '  has  so  well  de- 
scribed as  the  superior  pelvi-rectal  space,  the  space  between  the 
p'-rironeum  and  the  recto-vesical  fascia.  This  space  extends 
laterally  and  posteriorly  from  the  rectum  to  the  pelvic  wall  on 
all  sides.     It  is  filled  with  loose  connective  tissue  containing 

1  Traits  d'Anat.  Med.  Chir.,  3d  Edit.,  p.  828. 


RECTAL    HERNIA. 


199 


little  fat  in  its  meshes,  and  continuous  through  the  intervention 
of  the  general  sub-peritoneal  connective  tissue  with  that  filling 
the  concavity  of  the  sacrum  and  the  iliac  fossae.  It  also  com- 
municates with  the  genital  region  through  the  sciatic  notch,  and 
in  this  way  is  explained  the  extensive  burrowing  of  pus  in  some 
of  the  deep  varieties  of  fistula. 

The  pelvic  fascia  (1)  divides  into  two  layers  (2  and  5),  and 
the  line  of  division  is  shown  on  the  cadaver  by  a  tendinous  cord 
stretching  antero-posteriorly  on  each  side  of  the  pelvis  from  the 
symphysis  pubis  in  front  to  the  spine  of  the  ischium  behind. 
After  the  bifurcation  the  upper  layer  (2)  which  is  known  as  the 
recto- vesical  division  of  the  pelvic  fascia,  or  simply  as  the  recto- 


FiG.  65. — Diagrammatic  View  of  the  Pelvic  Diaphragm  as  seen  in  a  Lateral  Vertical  Sec- 
tion through  the  Pelvis  on  a  Line  with  the  Rectum.  R,  rectum  ;  1,  undivided  pelvic  fascia  ; 
2,  recto-vesical  division  of  the  pelvic  fascia ;  3,  anal  fascia  lining  the  under  surface  of  the 
levator  ani ;  4,  levator  ani  muscle ;  5,  obturator  division  of  the  pelvic  fascia ;  6,  superior 
pelvi-rectal  space  of  Richet ;  7,  ischio-rectal  fossa ;  P,  peritoneum. 

vesical  fascia,  follows  the  superior  surface  of  the  pelvic  dia- 
phragm down  to  the  rectum,  the  prostate,  and  the  bladder,  all 
of  which  it  encases  to  a  greater  or  less  extent  before  it  is  finally 
lost  in  a  thin  layer  upon  them.  From  this  layer  of  fascia  the 
anterior  and  lateral  ligaments  of  the  bladder  are  formed.  The 
outer  layer  of  the  divided  pelvic  fascia  (5)  is  known  as  the 
obturator  fascia  and  covers  the  inner  surface  of  the  obturator 
internus  muscle  ;  forming  also  the  outer  boundary  of  the  ischio- 
rectal fossa.  The  thin  layer  of  fascia  (3)  which  lines  the  under 
surface  of  the  levator  ani  and  is  known  as  the  anal  fascia,  is  a 
supplementary  division  of  the  general  pelvic  fascia. 

The  remaining  layer  of  the  pelvic  diaphragm  is  a  muscular 


200 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


and  tendinous  one,  the  levator  ani.  We  say  muscular  and 
tendinous  because  the  muscular  fibre  is  in  some  places  exceed- 
ingly thin,  and  in  others  entirely  wanting,  its  place  being  sup- 
plied by  aponeurotic  septa  and  the  tendinous  fibres  of  origin 
and  insertion,  which  are  very  thin  and  yet  possess  considerable 
strength.  This  muscle,  including  the  ischio-coccygeus,  which  is 
really  only  a  part  of  the  levator  ani,  has  already  been  described. 
What  the  abdominal  wall  is  to  an  inguinal  hernia  the  pelvic 
diaphragm  is  to  a  rectal  ;  and  for  this  reason  it  has  been  dwelt 
upon  to  such  length.  It  is  evident  that  no  protrusion  of  the 
pelvic  or  abdominal  contents,  except  in  the  form  of  intussuscep- 
tion, can  occur  into  the  rectum  and  out  of  the  anus  which  does 
not  either  pass  directly  through  it  or  carry  it  before  it  as  one 
of  the  layers  of  the  hernial  sac. 

IP 


R 


5  5 

FiG.  66. — Same  Section  as  Fig.  65,  showing  the  Commencement  of  the  Formation  of  the 
Hernial  Sac.   H,  Hernial  sac  lined  by  peritoneum  and  composed  of  all  the  coats  of  the  rectum. 

It  happens  as  a  matter  of  fact  that  the  hernial  contents 
do  pass  this  barrier  in  several  different  ways,  giving  rise  thus  to 
several  distinct  varieties  of  the  affection.  The  most  frequent 
form  is  that  represented  in  Fig.  66,  where  the  rectum  is  seen  at 
the  commencement  of  the  formation  of  a  prolapsus  which  itself 
forms  the  sac  of  the  hernia. 

The  inversion  of  the  rectum  is  here  shown  as  beginning  just 
at  the  point  where  the  pelvic  diaphragm  surrounds  the  bowel ; 
and  the  neck  of  the  hernial  sac  in  such  a  case  is  formed  by  the 
levator  and  the  pelvic  diaphragm.  The  sac  itself  is  composed 
of  all  the  layers  of  the  rectal  wall,  and  the  peritoneum  is  in  part 
that  which  covers  the  rectum  and  in  part  that  of  the  pelvic  dia- 
phragm, but  chiefly  the  former  because  of  its  more  ready  dis- 
placements. 


RECTAL    HERNIA. 


201 


Fig.  67  shows  the  advanced  condition  of  prolapsus,  and  the 
full  development  of  the  hernial  sac;  and  explains  why  the 
previous  existence  of  a  complete  prolapsus  is  the  most  common 
cause  of  rectal  hernia.  Whether  or  not  such  a  sac  contains  a 
hernia  is  in  great  measure  a  matter  of  accident.  As  is  the  case 
in  one  form  of  congenital  inguinal  hernia,  the  prolongation  of 
the  peritoneal  layer  which  lines  the  hernial  sac  is  there  waiting 
for  some  unusual  strain  or  the  gradual  increase  in  its  size  to 
complete  the  process  and  fill  the  sac  with  a  loop  of  intestine. 
The  peritoneal  sac  has  been  drawn  both  in  front  and  behind  the 
rectum,  and  on  this  point  the  drawing  is  directly  opposed  to 
the  statement  of  Allingham,  that  from  the  anatomy  of  the  part 
the  hernia  must  of  course  be  perineal.     There  is  no  doubt  that 


Fig.  67. — Sac  of  Rectal  Hernia. 


in  most  cases  the  sac  is  anterior,  but  there  seems  to  be  no 
anatomical  impossibility  in  its  being  posterior,  and  that  it 
sometimes  is  posterior  is  a  matter  of  clinical  experience.  In 
the  case  of  Englisch,  particular  attention  is  called  to  the  coils 
of  intestine  in  the  posterior  part  of  the  prolapsus,  though  they 
were  more  marked  in  front. 

Another  way  in  which  the  hernial  sac  may  be  formed  is 
shown  in  Fig.  68. 

Here  the  protrusion  has  occurred  between  the  rectum  and 
uterus,  and  the  hernia  is  the  direct  cause  of  whatever  prolapsus 
there  may  be,  instead  of  as  in  last  case,  the  prolapsus  being  the 
exciting  cause  of  the  hernia.  The  neck  of  the  hernia  in  this 
case  will  be  formed  by  a  direct  perforation  of  the  pelvic  dia- 


202 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


pliragm  in  all  of  its  layers  except  the  peritoneal,  which  is  car- 
ried forward  into  the  hernial  sac  ;  and  the  sac  is  formed  from 
the  front  or  side  of  the  rectal  wall.  The  protrusion  may  occur 
at  any  other  point  in  the  rectal  wall,  as  well  as  at  the  recto- 
vesical cul-de-sac,  obviously  at  the  point  behind  marked  by  a 
star,  or  at  a  point  higher  up  in  the  rectum  ;  and  such  a  hernia 
may  remain  entirely  within  the  bowel,  constituting  what  has 
been  referred  to  as  an  internal  rectal  hernia,  or  it  may  pass  be- 
yond the  external  sphincter  and  constitute  the  external  variety. 


Fid.  68.— Internal  Rectal  Hernia.     R  R,  rectum  laid  open  laterally  ;  H,  empty  hernial  sac 
with  its  neck  at  Douglas's  pouch,  protruding  into  and  filling  the  rectum  ;  .  .   .   .  Peritoneum. 

In  the  internal  variety  the  hernial  sac  may  be  composed  of 
all  the  layers  of  the  rectal  wall  minus  the  muscularis,  which  has 
been  ruptured,  and  allowed  the  protrusion  to  be  carried  through 
it,  instead  of  being  spread  out  over  its  surface. 

Another  variety  of  rectal  hernia  is  that  in  which  there  seems 
to  be  no  hernial  sac,  but  in  which  the  coils  of  intestine  lie  loose 
in  the  cavity  of  the  rectum  or  have  passed  bej^ond  the  sphinc- 
ter. These  are  the  cases  described  by  Quenu  as  spontaneous 
rupture  of  the  rectum,  to  distinguish  them  from  the  results  of 


EECTAL    HERNIA.  203 

direct  traumatism,  such  as  might  be  caused  by  a  foreign  body 
puncturing  the  rectal  wall  or  the  pelvic  diaphragm.  Many  of 
these  cases  are  undoubtedly  the  result  of  the  rupture  of  a  pre- 
viously existing  hernial  sac,  and  are  therefore  merely  complica- 
tions of  the  varieties  already  described.  In  the  case  of  Brodie, 
no  previous  prolapsus  is  mentioned,  and  the  rapture  is  believed 
to  have  been  the  result  of  an  accidental  tearing  of  the  rectal 
wall.  In  the  case  of  Quenu,  the  history  of  previous  prolapse 
was  carefully  sought  for  and  not  obtained ;  still  there  is  no 
proof  that  both  of  these  cases  might  not  have  been  complica- 
tions of  previously  existing  internal  hernise.  Quenu' s  patient 
gave  a  distinct  history  of  former  rectal  trouble  and  bloody  pas- 
sages ;  and  had  once,  two  years  before  the  rupture,  suffered 
from  some  kind  of  a  protrusion  from  the  anus,  which  he  had 
reduced  himself. 

In  the  cases  of  rupture  reported  by  Adelmann,  Pyl,  Roche, 
and  Schrager,  the  previous  existence  of  prolapsus  is  distinctly 
stated.  In  the  case  of  Stein,  no  data  are  given  upon  which  to 
base  an  opinion.  It  is  possible,  however,  that  rupture  of  the 
rectum  may  occur  as  a  result  of  severe  straining  where  there  has 
been  no  previous  hernia,  but  it  does  not  seem  probable  that  such 
rupture  ever  occurs  without  the  existence  of  previous  disease 
which  has  weakened  the  wall  of  the  rectum  at  the  point  where 
the  rupture  takes  place,  except  in  cases  of  direct  traumatism, 
as  in  childbirth  or  the  introduction  of  foreign  bodies  ;  or  in  the 
case  of  an  accident  such  as  is  reported  by  Nedham. 

In  the  case  of  Quenu  the  rectal  wall  seemed  to  the  naked 
eye  to  be  perfectly  healthy,  and  yet  an  examination  with  the 
microscope  showed  the  signs  of  inflammation  and  infiltration  of 
the  wall  with  white  globules.  In  Brodie' s  case  the  mucous 
membrane  is  said  also  to  have  been  healthy,  but  no  microscopic 
examination  is  reported,  and  the  statement  cannot,  therefore, 
be  allowed  much  weight.  In  all  the  cases  of  rupture  compli- 
cating previously  existing  hernise  a  change  in  the  hernial  sac  of 
a  character  to  render  rupture  easy  may  be  taken  for  granted,  if 
not  distinctly  stated  to  have  been  present.  In  Adelmann' s  case 
the  mucous  membrane  is  said  to  have  been  congested,  inflamed, 
and  eroded  in  spots.  In  Roche' s  case  the  prolapsus  had  been 
down  twenty-four  hours  and  "  had  resisted  all  the  attempts  of 
the  patient  and  her  fem,ale  friends  at  replacement."  Besides 
these  direct  statements  we  know  the  changes  which  occur  in  an 


204  DISEASES    OF    THE    RECTUM    AND    ANUS. 

old  prolapsus,  and  especially  in  an  irreducible  one.  These  are  a 
thickened,  eroded,  granular,  and  cedematous  condition  of  the 
mucous  membrane  ;  a  deposit  of  albuminous  material  in  the 
submucous  connective  tissue  ;  and  the  final  production  of  a 
foul,  hypertrophied,  eroded,  and  bleeding  mass.  Quenu  has 
studied  this  point  very  thoroughly  and  lays  great  stress  upon 
the  dilatation  and  alteration  of  the  veins.  The  straining  causes 
the  rupture  of  a  vein,  and  the  infiltration  of  blood  among  the 
diseased  tunics  of  the  prolapsed  rectum  causes  their  rupture. 
There  is  an  oedema  of  the  hernial  sac,  a  catarrh  of  the  mucous 
membrane,  a  dilatation  of  the  veins  of  the  mucous  and  sub- 
mucous tissue  ;  the  wall  of  the  vein  becomes  infiltrated  with 
leucocytes,  and  the  predisposition  to  rupture  is  established.  An 
effort  at  abdominal  expulsion  increases  the  tension  of  the  blood 
in  the  dilated  vessels  rendered  feeble  by  inflammation  ;  a  vein 
ruptures  as  in  a  varix  of  the  extremities  ;  the  blood  percolates 
the  layers  of  the  sac  all  the  more  readily  as  the  infiltration  of 
white  corpuscles  has  prepared  the  way  ;  and  the  walls  of  the 
bowel,  dissected  up  by  the  blood  and  already  altered,  finally 
give  way. 

The  rupture  may  occur  at  any  point  in  the  hernial  sac,  or  in 
the  rectal  wall  when  no  hernial  sac  is  discoverable.  Thus  in 
Quenu' s  personal  case  it  was  in  the  anterior  wall  of  the  up]:>ei' 
part  of  the  rectum  a  little  to  the  left  of  the  median  line,  its 
lower  end  reaching  to  within  8  ctm.  of  the  recto-vesical  cul-de- 
sac.  In  Adelmann's  case  the  rent  was  longitudinal,  2%"  above 
the  anus.  In  Pyl's  case  it  was  on  the  posterior  wall  an  inch 
from  the  anus;  in  Stein's  case  on  the  anterior  wall ;  in  Roche's 
case  it  was  longitudinal  at  a  "considerable  distance  from  the 
anus  ; "  in  Brodie's  case  it  was  anterior,  2"  from  the  anus. 

The  length  of  the  rupture  ma}'  also  vary  greatly.  In  Adel- 
mann's case  it  was  2£"  long  ;  in  Stein's  10"  ;  in  Roche's  its  ex- 
tent could  not  be  determined  without  an  autopsy  ;  in  Pyl's,  four 
fingers'  breadth  ;  in  Quenu's  it  was  4.3  ctm.  in  the  mucous  mem- 
brane, and  10  ctm.  in  the  peritoneum. 

The  rupture  is  probably  always  due  to  force  applied  from 
within  the  hernial  sac  or  from  the  direction  of  the  abdominal 
toward  the  rectal  cavity,  and  not  vice  versa,  and  the  peritoneal 
coat,  on  account  of  its  greater  tenuity  and  slight  elasticity,  is 
probably  th»>  first  to  give  way.  The  immediate  cause  of  the 
rupture  is  probably  an  over-distention  of  the  sac  with  loops  of 


RECTAL    HERNIA.  205 

intestine  filled  with  gas  and  faeces,  and  then  a  straining  on  the 
part  of  the  patient  by  which  fresh  coils  of  intestine  or  more  air 
and  faeces  are  forced  into  the  sac.  Brodie's  occurred  during  an 
effort  at  vomiting;  Stein's  while  lifting  a  heavy  weight;  and 
those  of  Quenu  and  Adelmann  during  the  act  of  defecation  ; 
Pyl's  case  occurred  also  during  defecation,  but  the  patient  had 
just  previously  been  thrown  upon  the  floor  and  the  hernia  was 
probably  injured  in  the  fight.  In  the  cases  of  Streubel  and 
Ohle,  the  opening  in  the  hernial  sac  was  due  to  surgical  inter- 
ference ;  and  in  Roche's  case  the  rupture  occurred  during  the 
surgeon's  forcible  attempts  at  reduction. 

The  contents  of  the  hernial  sac  are  generally  loops  of  small 
intestine  ;  quite  frequently,  however,  portions  of  the  colon  and 
sigmoid  flexure  have  been  found  ;  in  Stocks' s  and  Pockel' s  cases 
an  ovary  ;  and  in  Brunn's  and  Englisch's  cases  the  uterus.  The 
size  of  the  hernia  ma}7  be  so  small  as  to  lead  the  unwary  into 
the  belief  that  it  is  a  simple  prolapse  composed  entirely  of  mu- 
cous membrane,  or  it  may  reach  the  dimensions  of  an  adult 
head.  After  the  rupture  of  the  sac  the  intestine  may  escape  to 
the  length  of  several  yards. 

A  rectal  hernia,  like  one  into  the  scrotum,  may  be  reducible, 
irreducible,  inflamed,  or  strangulated. 

A  rectal  hernia  which  has  previously  been  reducible  with 
proper  manipulation,  may  become  irreducible  from  a  variety  of 
circumstances.  The  obstacle  to  reduction  may  be  at  the  neck 
of  the  hernia  outside  of  the  sac,  or  within  the  hernial  sac.  As 
is  the  case  in  any  hernia  of  the  intestine,  it  may  be  reducible 
when  the  coils  of  intestine  filling  the  sac  are  empty,  and  irredu- 
cible when  they  by  chance  become  distended  with  gas  or  faeces. 
Or  the  neck  of  a  hernial  sac  which  will  allow  the  passage  back 
and  forth  of  a  certain  amount  of  intestine,  may  not  allow  of  the 
return  of  an  unusual  quantity  which  has  been  forced  through 
it  by  some  unusual  pressure.  Bat  probably  a  more  common 
reason  for  the  irreducibility  of  a  rectal  hernia  which  is  not 
strangulated  will  be  found  in  an  inflammation  of  the  sac,  which 
lias  united  the  peritoneal  lining  with  the  peritoneal  covering  of 
the  contained  intestine.  A  chronic  inflammation  of  a  rectal 
hernia  is  by  no  means  uncommon.  This  is  generally  the  con- 
dition of  the  mucous  membrane  covering  the  sac,  and  it  is  due 
to  its  exposed  position,  and  the  frequent  slight  injuries  it  re- 
ceives. 


206  DISEASES    OF   THE    RECTUM    AND    ANUS. 

If  the  injury  be  more  severe,  as  a  kick  or  a  blow,  or  if  the 
sac  be  exposed  to  cold  or  wet,  there  may  supervene  an  acute 
peritonitis  starting  in  the  sac  and  possibly  extending  to  the 
general  cavity  of  the  abdomen.  Such  an  inflammation  will 
generally  be  ushered  in  by  a  chill  and  more  or  less  pain  in  the 
hernia  and  abdomen.  The  inflammation  is  shown  by  the  dark, 
brownish,  ecchymosed  appearance  of  the  mucous  membrane,  by 
its  dryness  or  the  presence  of  a  muco-purulent  or  bloody  dis- 
charge ;  by  the  loss  of  elasticity  in  the  sac  which  results  from 
the  infiltration  of  its  different  layers  and  by  its  increased  fri- 
ability, and  the  constant  spasm  of  the  sphincter.  There  may  be 
an  increase  in  the  size  of  the  hernia  from  distention  of  its  con- 
tents with  gas  as  the  peristaltic  action  ceases  under  the  inflam- 
mation ;  and  finally,  the  signs  of  intestinal  obstruction  with 
general  peritonitis.  Such  a  condition  may  result  in  gangrene 
and  in  perforation.  Brunus  case  was  one  in  which  inflamma- 
tion of  an  irreducible  hernia  ended  fatally,  and  in  Uhde's  case 
gangrene  and  death  were  the  result. 

When  perforation  results  an  artificial  anus  is  formed.  If 
the  perforation  happen  to  be  outside  of  the  sphincter  the  con- 
dition is  easily  diagnosticated  by  simple  inspection.  If  the  her- 
nia be  an  internal  one,  or  if  a  fistulous  communication  be  es- 
tablished between  the  small  intestine  contained  in  the  hernial 
sac  and  the  cavity  of  the  rectum  above  the  point  which  can  be 
reached  by  a  digital  examination,  it  may  entirely  escape  diag- 
nosis. 

Another  condition  which  may  render  a  hernia  irreducible  is 
strangulation,  and  in  this  as  in  abdominal  hernise  the  constric- 
tion will  be  found  at  the  neck  of  the  sac,  in  other  words  at  the 
level  of  the  pelvic  diaphragm.  It  is  possible  that  if  a  mass  of 
intestine,  with  or  without  a  hernial  sac,  has  been  forced  out  of 
the  anus,  where  there  has  been  no  pre-existing  prolapsus, 
strangulation  may  be  caused  by  a  contraction  of  the  sphincter 
muscle ;  but  in  general  the  power  of  this  muscle  has  been  so 
weakened  by  previous  stretching  that  it  is  incapable  of  causing 
strangulation,  and  the  constriction  will  be  found  at  the  level  of 
the  levator  ani,  and  on  the  front,  back,  or  side  of  the  rectum, 
wherever  the  neck  of  the  hernia  may  chance  to  be. 

Diagnosis. — Nothing  need  be  said  upon  the  diagnosis  of  a 
rectal  hernia  in  which  the  coils  of  intestine  protrude  from  the 
anus  uncovered  by  any  hernial  sac.     In  such  a  case  a  mistake 


RECTAL   HERNIA.  207 

would  seem  to  be  well  nigh  impossible.  In  an  internal  rectal 
hernia  (one  which  has  not  passed  the  anus)  the  diagnosis  will 
lie  between  it  and  an  intussusception  ;  but  a  careful  examina- 
tion with  the  finger,  or  the  whole  hand  if  necessary,  should  re- 
veal the  presence  of  a  sac  containing  loops  of  intestine  which 
can  be  pressed  out  of  it  into  the  general  peritoneal  cavity  ;  of  a 
pedicle  to  the  tumor  thus  formed  ;  and  of  an  opening  in  the 
wall  of  the  bowel  which  constitutes  the  mouth  of  the  sac. 

In  ordinary  cases  of  hernia  which  have  become  external,  the 
diagnosis  will  lie  between  hernia  and  prolapsus  without  hernia. 
Often  the  different  coils  of  intestine  within  the  prolapsus  can  be 
felt  between  the  fingers,  the  index  finger  being  passed  up  into 
the  rectum  and  the  thumb  remaining  outside.  The  coils  may 
also  be  reduced  from  the  sac  with  a  gurgling  noise,  and  the  sac 
may  be  tympanitic  on  percussion,  especially  in  front.  The 
thickness  of  the  mass  and  its  pear-shape  are  also  points  of  im- 
portance, and  the  peculiar  enlargement  in  circumference  which 
it  undergoes  when  the  patient  strains,  instead  of  the  mere 
lengthening  which  occurs  under  similar  circumstances  in  a 
simple  prolapsus.  A  careful  examination  here  also  may  enable 
the  surgeon  to  trace  the  pedicle  up  into  the  pelvis,  and  the  po-^ 
sition  of  the  opening  into  the  rectum  as  it  is  turned  back 
toward  the  coccyx  by  the  bulging  of  the  anterior  portion  of  the 
tumor,  is  worthy  of  notice.  The  diagnosis  is  always  compli- 
cated by  the  condition  of  irreducibility,  but  even  here  tym- 
panitic resonance  on  percussion,  and  gurgling  of  air  on  palpa- 
tion, remain  to  assist  the  examiner.  The  flattened  appearance 
of  the  lower  abdomen,  the  sinking  in  of  the  umbilicus,  and  the 
folds  of  the  abdominal  wall  radiating  from  it,  may  also  indicate 
that  the  abdomen  has  lost  a  part  of  its  natural  contents. 

Treatment. — The  treatment  of  rectal  hernia  at  once  divides 
itself  into  curative  measures  for  the  uncomplicated  condition, 
and  the  treatment  of  the  complications — inflammation,  strangu- 
lation, and  rupture. 

In  reducing  a  rectal  hernia  the  same  accident  may  happen 
as  in  other  hernise,  and  the  sac  and  its  contents  may  be  pushed 
above  the  sphincter  en  masse.  This  is  best  avoided  by  keeping 
a  firm  hold  upon  the  sac  while  the  intestinal  loops  are  expressed 
from  it. 

A  reducible  rectal  hernia  may,  after  reduction  has  been  ac- 
complished, be  treated  as  would  an  old  and  extensive  prolapsus 


*208  DISEASES    OF    THE    RECTUM    AND    ANUS. 

without  hernial  contents,  and  it  is  unnecessary  to  recall  the 
various  measures  in  the  hands  of  the  surgeon  for  dealing  with 
this  condition.  But  rectal  hernia  is  a  more  serious  condition 
than  prolapsus,  and  certain  more  radical  measures  may  be 
justifiable  in  the  treatment  of  it  than  would  be  in  dealing  with 
an  affection  which,  however  disagreeable,  does  not  generally  en- 
danger life.  In  cases  where  free  and  extensive  cauterization 
lias  failed  to  keep  the  hernia  within  the  anus,  nothing  remains 
but  the  ablation  of  the  sac,  an  operation  fraught  with  the 
greatest  danger  to  the  life  of  the  patient.  A  glance  at  the  table 
of  cases  will  show  that  Uhde  abandoned  the  idea  on  account  of 
the  strangulation  of  the  hernia  and  the  collapse  of  the  patient ; 
and  that  Streubel  cut  off  the  sac  with  the  ecraseur  and  the 
hernial  contents  protruded  through  the  wound  on  the  following 
day  with  fatal  result.  The  case  mentioned  by  Van  Buren  ended 
in  much  the  same  way  in  spite  of  the  sutures  which  were  in- 
troduced to  prevent  the  escape  of  the  hernial  contents.  Smith 
operated  in  a  similar  case  with  his  clamp  and  cautery  and  had 
the  same  accident,  though  the  case  terminated  favorably.  These 
results  seem  to  point  to  the  advantages  of  any  method  which 
will  more  certainly  insure  the  avoidance  of  an  appearance  of 
coils  of  intestine  through  the  wound,  and  the  following  case  by 
Kleberg'  was  more  successful. 

Case. — Operation  for  Rectal  Hernia. — In  this  case  the  pro- 
lapse was  about  a  foot  in  length  and  six  inches  in  diameter. 
The  mucous  membrane  was  spongy,  bleeding,  excoriated,  and 
ulcerated.  The  patient  had  been  sick  for  two  years,  had  been 
bed-ridden  for  two  months,  and  was  waxy  pale. 

On  the  previous  day  a  dose  of  castor-oil  was  given,  and  on  the 
morning  before  the  operation  an  enema  of  lukewarm  water  was 
administered  high  up  the  bowel.  Immediately  before,  a  glass 
of  wine  and  one  grain  of  opium  were  given.  After  the  patient 
had  pressed  down  the  gut  as  far  as  he  could  he  was  placed  on 
the  operating  table  in  the  lateral  position  with  the  pelvis  raised 
and  shoulders  turned  downward.  Chloroform  was  then  ad- 
ministered. In  two  cases  Kleberg  has  operated  without  chloro- 
form because  the  patients  were  in  such  a  miserable  condition 
that  he  was  afraid  to  narcotize  them  thoroughly,  and  an  incom- 
plete  narcosis  has  all  the  dangers  of  profound  anaesthesia  and 

1  Ueber  die  Anwendung  der  elastischen  Ligatur  zur  Operation  sehr  echwerer  Falle 
von  Prolapsus  Recti.     Arch,  fur  Klin.  Chirurg.,  vol.  xxiv.,  p.  840. 


EECTAL    HERNIA.  209 

none  of  its  advantages.  After  the  chloroform,  he  says,  "I  care- 
fully examined  about  the  rectum,  at  the  junction  of  the  skin 
and  mucous  membrane,  in  order  to  discover  the  sphincter  ani — 
a  procedure  that  was  more  difficult  than  one  would  think,  be- 
cause it  had  become  so  stretched  and  atrophied  that  I  could 
only  make  it  out  by  feeling  under  the  fingers  the  coarser  fibres 
running  across  the  longitudinal  axis  of  the  bowel.  Of  anything 
like  the  normal  muscle  there  was  nothing  to  be  discovered. 

"An  assistant,  at  this  point,  surrounded  with  all  the  fingers 
the  prolapsus  from  above,  the  points  of  the  fingers  being  di- 
rected toward  the  free  end  of  the  prolapsus,  and  pressed  as  hard 
as  possible  into  the  gut  at  a  point  perhaps  half  an  inch  below 
the  supposed  sphincter.  Immediately  in  front  of  the  ends  of 
the  assistant's  fingers  I  then  placed  a  good,  fresh,  unfenestrated 
drainage-tube  of  rubber,  one  and  one-half  line  in  diameter, 
around  the  prolapsus,  and  drew  it  only  as  tight  as  seemed  nec- 
essary to  stop  the  circulation.  The  elastic  ligature  was  brought 
to  the  necessary  tension  by  means  of  an  easily-untied  slip-knot 
of  silk  thrown  under  it. 

"  The  assistant  now  had  both  hands  free  ;  and  from  this  time 
on  the  operation  was  performed  under  the  carbolic  spray.  A 
few  lines  beneath  the  ligature  I  now  made  a  longitudinal  in- 
cision two  inches  long  through  the  prolapsed  gut,  and  in  this 
way  opened  the  sac  formed  by  the  drawing  down  of  the  peri- 
toneum. Then  I  seized  the  elastic  ligature  with  the  forceps  and 
fixed  it  firmly.  It  was  thus  an  easy  matter  to  push  back  into 
the  peritoneal  cavity  a  protruding  loop  of  intestine  without  the 
slightest  bleeding  taking  place  into  the  wound  or  any  air  enter- 
ing the  peritoneal  cavity ;  because  the  elastic  pressure  follows 
so  rapidly  all  the  movements  that  no  opening  can  exist  any- 
where. 

"After  I  had  convinced  myself  that  the  peritoneal  sac  was 
empty,  and  that  no  invagination  of  the  intestine  was  present, 
but,  on  the  other  hand,  only  that  part  of  the  gut  which  was  to 
be  removed  lay  in  front  of  the  ligature,  I  thrust  the  largest  size 
Luer's  pocket  trocar  through  the  prolapsus,  immediately  below 
the  elastic  ligature,  from  before  backward,  and  passed  through 
the  canula  two  elastic  drainage-tubes  of  one  and  one-half  line 
in  diameter,  and  after  removing  the  canula,  tied  them  as  tightly 
as  possible,  one  on  the  right  side,  the  other  on  the  left.  These 
knots  were  secured  against  slipping  by  means  of  the  knot  of 

14 


210  DISEASES    OF    THE    RECTUM    AND    ANUS. 

silk.  The  first  provision  against  haemorrhage — the  elastic  liga- 
ture applied  after  Esmarch's  plan — was  then  removed  and  the 
prolapsus  cut  off  with  the  scissors  one  inch  in  front  of  the  per- 
manent ligatures.  After  a  few  minutes'  time,  during  which  I 
kneaded  the  parts  which  still  remained  and  lay  above  the  liga- 
tures thoroughly,  and  as  far  as  possible  removed  the  fluids  from 
them,  I  covered  the  parts  around  the  stump  with  cotton,  and 
soaked  the  part  of  the  prolapse  which  still  remained  above  the 
ligature  with  a  solution  of  chloride  of  zinc,  dried  it,  squeezed  the 
soft  parts  once  more,  thoroughly  applied  the  chloride  of  zinc 
again,  and  then  covered  the  whole  with  dry  cotton-batting,  giv- 
ing the  patient  instructions  to  remove  this  as  soon  as  it  became 
moist  and  to  replace  it  with  dry,  and  to  give  the  air  all  possible 
access  to  the  parts." 

No  fever  followed  the  operation,  and  the  pain  was  bearable, 
with  the  aid  of  an  occasional  opiate.  On  the  next  day  the  parts 
had  so  far  shrunk  as  to  leave  a  concavity  at  the  anus  where  be- 
fore there  had  been  a  bulging.  There  was  no  bleeding,  no  peri- 
toneal irritation,  and  only  slight  tenesmus.  On  the  fourth  day 
the  first  ligature  cut  out,  and  the  second  on  the  fifth.  The  rec- 
tum was  irrigated  twice  a  day  with  water  and  permanganate  of 
potash,  and  on  the  seventh  day  a  dose  of  castor-oil  was  followed 
by  a  large  evacuation  while  the  patient  was  on  his  back,  without 
pain  or  haemorrhage.  The  passage,  however,  was  involuntary. 
On  the  fourteenth  day  the  wound  was  healed,  the  general  con- 
dition of  the  patient  excellent,  and  the  evacuations  regular  but 
still  involuntary.  The  sphincter  at  this  time  began  to  be  ap- 
preciable, and  there  was  no  protrusion  of  the  bowel,  the  patient 
going  about  and  wearing  a  bandage.  One  month  later  he  had 
control  of  solid  faeces,  but  there  was  still  a  slight  discharge  of 
mucus  ;  and  after  another  month  he  was  entirely  well. 

Another  case  by  the  same  surgeon  and  the  same  method 
ended  fatally,  but  can  hardly  be  considered  a  fair  test  of  the 
dangers  of  the  operation,  on  account  of  the  exceedingly  bad 
condition  of  the  patient  ;  still  the  operation  is  one  of  extreme 
gravity,  and  its  results  so  far  have  not  been  encouraging. 

The  existence  of  an  irreducible  rectal  hernia,  even  without 
any  signs  of  acute  inflammation,  justifies  the  division  of  the  con- 
striction and  its  reduction  ;  for  such  a  hernia,  unlike  one  in  the 
scrotum,  is  constant^  subject  to  influences  which  may  at  any 
moment  excite  a  fatal  peritonitis. 


RECTAL    HERNIA.  211 

In  cases  of  inflamed  rectal  hernia,  the  treatment  should  be 
directed  toward  reducing  the  inflammation  by  rest,  local  anti- 
phlogistic measures,  and  opium.  If  reduction  be  possible  it 
may  be  performed.  If  reduction  be  impossible  and  the  hernia 
acutely  inflamed,  it  must  be  treated,  as  a  strangulated  hernia 
elsewhere  would  be,  by  operation  tending  to  divide  the  constric- 
tion causing  the  strangulation.  If  the  constriction  seems  to  be 
at  the  sphincter  ani  it  can  easily  be  overcome  by  stretching 
without  a  cutting  operation  and  without  opening  the  peri- 
toneum. If  it  be  at  the  neck  of  the  sac  the  same  manoeuvre 
may  be  possible.  Various  methods  of  subcutaneous  section  of 
the  constriction  have  been  recommended,  but  none  of  them  rest 
upon  any  clinical  experience. 

If  the  constriction  cannot  be  overcome  by  stretching  with 
the  fingers,  and  if  reduction  cannot  be  accomplished  by  this 
means  joined  with  anaesthesia,  nothing  remains  but  a  longitu- 
dinal incision  into  the  hernial  sac  as  near  the  neck  as  possible, 
and  the  division  of  the  neck  with  the  hernia  knife  as  in  an 
ordinary  case  of  strangulated  hernia. 

In  case  a  rupture  of  the  sac  or  of  the  rectum  has  already 
occurred  and  the  intestines  have  escaped  through  the  rent, 
there  is  still  much  for  the  surgeon  to  do,  although  the  prognosis 
is  almost  fatal.  Smith's  case  recovered,  but  here  the  accident 
occurred  directly  under  the  eye  of  the  operator,  and  the  bowel 
was  immediately  replaced  before  it  had  been  long  exposed  to 
the  air  or  had  become  inflamed.  In  Streubel's  case,  where  a 
somewhat  similar  accident  occurred  on  the  day  after  the  opera- 
tion, the  result  was  fatal. 

It  will  be  noticed  that  in  every  case  but  one  where  the 
rupture  has  been  due  to  violence,  death  has  been  the  conse- 
quence ;  and  also  that  in  every  case  but  that  one  (Nedham's)  an 
effort  has  been  made  at  reduction,  even  though  laparotomy 
were  necessary  for  its  accomplishment. 

There  is  no  doubt  that  the  first  duty  of  the  surgeon  is  to 
replace  the  mass  witliin  the  abdomen  after  cleansing  it,  and 
this  is  seldom  an  easy  matter.  The  amount  protruded  is  often 
enormous,  it  is  also  generally  distended  with  gas  and  faeces ; 
the  rent  through  which  it  must  be  returned  is  more  or  less  con- 
cealed from  vision  and  touch  ;  and  the  intestines  constantly 
tend  to  pass  upward  into  the  rectum  above  the  rent,  rather 
than  into  the  peritoneal  cavity.     As  Quenu,  who  has  thoroughly 


212  DISEASES    OF    THE    RECTUM    AND    ANUS. 

handled  this  branch  of  the  subject,  suggests,  those  loops  which 
have  descended  last,  and  are  therefore  the  last  changed  in  ap- 
pearance, should  first  be  returned.  A  part  of  the  contents  of 
the  bowel  may  be  pressed  back  into  the  abdomen  by  gentle 
manipulation,  and  punctures  may  be  made  to  evacuate  the  re- 
mainder. The  reduction,  however,  has  seldom  been  completely 
accomplished  without  recourse  to  laparotomy. 

After  the  reduction  has  been  accomplished  the  rent  must  be 
closed  by  sutures — in  itself  an  exceedingly  difficult  task,  but 
one  which  is  rendered  easier  by  the  abdominal  wound  already 
made  ;  and  which  might  be  still  further  facilitated  by  a  pos- 
terior enlargement  of  the  anus  by  incision.  After  the  rectal 
wound  has  been  sutured  the  abdominal  one  may  be  closed,  a 
tampon  applied  to  the  rectum,  and  opium  with  fluid  diet  ad- 
ministered ;  but  the  chances  of  a  favorable  termination  of  the 
case  are  very  slight,  the  patient  generally  dying  of  collapse  or 
peritonitis. 

If  the  protruded  bowel  be  greatly  inflamed,  and  approach- 
ing gangrene  in  appearance,  the  surgeon  must  choose  between 
replacing  it  and  cutting  it  off.  Nedham's  fortunate  result  is 
attributed  by  most  writers  to  a  lucky  chance ;  but  it  cannot 
fail  to  strike  the  reader  that  had  he  insisted  upon  opening  the 
abdomen  and  replacing  the  mass  of  inflamed  bowel,  instead 
of  cutting  it  off  as  he  did,  the  chance  of  recovery  might  have 
been  much  less.  These  cases  in  the  future  must  be  studied  and 
treated  in  the  light  of  the  recent  results  of  intestinal  resection. 


CHAPTER  IX. 

NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS. 

Polypus. — Definition. — Hypertrophy  of  Villi. — Characteristics. — Villous  Tumor. — 
Adenomatous  Polypus. — Fibrous  Polypus. — Structure;  Characteristics. — Symp- 
toms of  Polypus  —Diagnosis. — Diagnosis  from  Malignant  Disease. — Treatment. 
— Vegetations. — Definition. — Description.  —  Microscopic  Appearances. — Relation 
to  Syphilis. — Symptoms  of  Vegetations. — Diagnosis. — Treatment. — Condylomata. 
— Distinction  between  Condylomata  and  Vegetations. — Description. — Syphilitic 
and  N on  syphilitic  Condylomata. — Benign  Fungus. — Gummata. — Rarity  and  Lit- 
erature.—  Anorectal  Syphiloma. —  Definition  of  Fournier. —  Fibromata. —  Lipo- 
mata.  — Characteristics.  — Enchondromata.  — Cysts.  — Dermoid  Growths.  — Charac- 
ters.— Pilo-Nidal  Sinus. — Hydatids. — Fcetal  Inclusions. — Spina  Bifida. — Congen- 
ital Cysts. 

Under  this  head  will  be  included  polypus,  vegetations,  condy- 
lomata, benign  fungus,  gummata,  ano-rectal  syphiloma,  fibro- 
mata, lipomata,  enchondromata,  and  the  various  forms  of  cysts. 

Polypus. — A  polypus  may  be  defined  as  a  benign  tumor 
composed  of  one  or  more  of  the  normal  elements  of  the  wall  of 
the  rectum  ;  an  hypertrophy  either  of  the  mucous  membrane  or 
of  the  submucous  connective  tissue.  Those  which  are  composed 
of  the  elements  of  the  mucous  membrane  are  known  and  gen- 
erally spoken  of  as  "  soft"  polypi ;  while  those  into  which  the 
submucous  connective  tissue  enters  are  known  as  the  "hard" 
or  fibrous.  In  many  works  the  former  class  are  spoken  of  as 
the  polypi  of  childhood,  and  the  latter  as  those  of  adult  age — a 
classification  of  little  practical  value. 

The  mucous  membrane,  as  has  been  shown,  is  composed  of 
villi,  of  the  follicles  of  Lieberkuhn  or  tubular  glands,  and  of  oc- 
casional closed  or  solitary  follicles.  A  polypus  composed  of  an 
hypertrophy  of  the  villi  is  well  represented  in  Fig.  69. 

A  polypus  of  this  variety  may  reach  the  size  of  a  pigeon's 
egg,  it  is  soft  to  the  feel,  and  has  a  shaggy  or  cauliflower  sur- 
face. On  section  the  cut  surface  is  of  grayish-red  color,  the 
substance  of  the  growth  homogeneous,  and  the  fluid  which  may 
be  forced  from  it  by  pressure  will  be  found  to  be  full  of  cylin- 


214 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


drical  epithelium.  A  microscopic  examination  shows  it  to  be 
composed  of  long  fine  papillae  bifurcated  at  their  extremities 
and  covered  by  cylindrical  epithelium.1 

Although  these  polypi  are  generally  small,  Dr.  Goodsallhas 
reported  a  case  from  St.  Mark's  Hospital,2  in  which  the  tumor 
attained  the  size  of  an  orange.  It  was  rough  and  tuberculated 
on  the  surface,  and  was  attached  to  the  rectal  wall  by  a  pedicle 
long  enough  to  permit  of  its  extrusion  from  the  anus  without 
pain.    It  was  attended  by  a  frequent,  copious,  watery  discharge, 


Fig  69.— Rectal  Polypus.     (Esmarch.) 

but  never  by  any  very  free  hasmorrhage  at  one  time,  and  the 
patient  showed  no  emaciation. 

Villous  Polypus  (granular  papilloma,  Gosselin ;  villous  tu- 
mor, Curling;  villous  polypi,  Esmarch;  "peculiar  bleeding 
tumor,"  Quain). — Fig.  70. 

It  is  a  question  whether  this  form  of  growth  should  be  clas- 
sified  with  the  polypi  already  described  or  with  the  warty 
growths,  whose  description  is  to  follow.  It  consists  of  an  hy- 
pertrophy both  of  the  villi  and  of  the  follicles  of  Lieberkuhn, 

1  Liicke  :  Die  Geschwulste.     Handbuch  der  allgemeinen  und  speciellen  Chirurgie. 
Pitha  u.  Billroth,  p.  250. 

5  Lancet,  May  21,  1881,  p.  828. 


NON-MALIGNANT  GEOWTHS  OF  THE  EECTUM  AND  ANUS.       215 

with  a  centre  of  connective  tissue  and  generous  vascular  supplv. 
According  to  the  description  given  by  Dr.  A.  Clark  '  of  a  speci- 
men in  the  London  Hospital  Museum,  the  tumor  is  "  essentially 
an  outgrowth  of  dense  areolar  tissue,  permeated  by  blood-ves- 
sels, and  assuming  a  papillary  form,  the  papillge  being  flattened 
and  curled  so  as  to  represent  hollow  cylinders,  and  being  clothed 
with  layers  of  epithelium,  the  free  layers  being  cylindrical." 


Pig.  70.— Villous  Polypus.     (Bryant.) 


These  tumors  are  very  rare  ;  they  have  the  feel  of  a  large 
warty  polypus  with  cauliflower  surface  ;  are  of  red  color  ;  bleed 
easily  ;  are  of  relatively  slow  growth,  existing  in  Rowland's 
case  several  years.  They  adhere  to  the  wall  of  the  rectum  by  a 
pedicle,  sometimes  composed  chiefly  of  mucous  membrane,  and 
at  others  large,  short,  and  fleshy. 

The  pedicle  may  be  absent  (Curling) ;  and  the  growth  will 
vary  in  structure  according  to  the  proportion  of  its  different 

1  Curling,  op.  cit.,  p.  85. 


216 


DISEASES    OF    THE    EECTUM    AND    ANUS. 


elements.  It  may  reach  the  size  of  an  orange  ;'  it  is  found  only 
in  adults  or  in  old  persons,  and  the  symptoms  are  the  same  as 
those  caused  by  other  polypi,  viz.,  discharge  and  haemorrhage  ; 
but  the  haemorrhage  is  not  a  constant  symptom,  and  varies 
greatly  in  frequency  and  amount  in  different  cases. 

Glandular  Polypus. — The  adenomatous  polypi,  or  those  de- 
veloped from  the  glands  of  the  mucous  membrane,  are  well 
shown  in  Fig.  71. 

These  may  be  due  either  to  an  hypertrophy  of  the  follicles 
of  Lieberkuhn  or  to  an  hypertrophy  of  the  closed  follicles. 


FlO.  71. —Glandular  Polypus.     (Esmarch.) 

They  occur  most  frequently  in  young  persons  ;  are  generally  of 
the  size  of  a  small  plum,  rarely  reach  that  of  a  pear,  and  yet 
Esmarch  reports  one  weighing  four  pounds."  They  are  very 
vascular  tumors,  and,  therefore,  of  reddish  color  ;  they  are 
sometimes  smooth  on  the  surface,  but  oftener  mammillated, 
like  a  strawberry,  and  are  attached  by  a  pedicle,  most  often  to 
the  posterior  wall,  but  occasionally  to  the  sides  of  the  rectum, 
and  at  a  point  generally  within  reach  of  the  finger,  but  some- 
times higher  up.  They  may  indeed  occur  anywhere  along  the 
large  intestine  as  high  up  as  the  ileo-caecal  valve. 

1  Syme :  Diseases  of  the  Rectum,  2d  ed.,  p.  82. 
aOp.  cit.,pp.  170,  177. 


NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS.       217 

The  pedicle  is  generally  large  and  short,  and  not  long  and. 
slender  as  in  the  case  of  the  fibrous  polypi  soon  to  be  described  ; 
but  there  are  frequent  exceptions  to  this  rule,  and  these  tumors 
will  sometimes  be  spontaneously  expelled  by  rupture  of  the 
slender  pedicle  in  defecation. 

The  pedicle  is  also  sometimes  double  (Smith).  It  consists  of 
mucous  membrane  covering  the  vessels  which  carry  the  blood 
to  the  tumor,  and  return  it  again — an  artery  and  generally 
two  veins,  but  when  the  tumor  is  very  large,  sometimes  two 
arteries  and  a  collection  of  veins. 

Polypi  which  consist  of  an  hypertrophy  of  the  closed  fol- 
licles of  the  rectum  are  often  found  in  considerable  numbers. 
Fochier '  removed  several  hundred  of  them  from  a  patient  aged 
eighteen,  and  Richet2  from  sixty  to  a  hundred  in  a  man  aged 
twenty-one.  Van  Buren 3  speaks  of  the  same  condition,  adopt- 
ing Broca's  name  of  "polyadenomata."  To  this  variety  of 
polypus  belong  also  certain  cysts  (closed  follicles),  distended 
by  viscid  and  transparent  fluid  ;  and  Bathurst  Woodman  has 
reported  one  such  case  in  which  the  cyst  was  lined  by  a  mem- 
brane similar  to  peritoneum. 

On  section  these  adenomatous  polypi  are  found  to  contain 
much  viscid  fluid,  full  of  cylindrical  epithelium  and  rudi- 
mentary glandular  tubes.  Under  the  microscope  a  vascular 
stroma  of  connective  tissue  will  be  found,  in  which  there  are 
enlarged  glandular  tubes,  sometimes  branching  at  their  extremi- 
ties, and  also  cystoid  spaces  filled  with  reddish  viscid  fluid 
(Esmarch). 

The  microscopic  appearances  of  a  section  of  such  a  polypus 
are  shown  in  Fig.  72. 

Fibrous  Polypus. — The  hard  or  fibrous  polypus  (sarcoma- 
tous polypus,  Esmarch),  which  is  composed  primarily  of  the 
elements  of  the  submucous  connective  tissue,  is  much  rarer  than 
the  soft  variety,  and  is  most  commonly  found  in  adults,  where 
it  may  be  isolated  or  multiple.  It  is  chiefly  composed  of  fibrous 
tissue,  and  resembles  the  uterine  fibroid  ;  but  it  may  contain 
both  muscular  and  glandular  elements.  When  the  glandular 
elements  are  filled  with  fluid  which  resembles  glue,  these  tumors 
have  been  known  as  colloid,  and  when  cysts  are  found  filled 

1  Molliere,  p.  362.     Note. 

2  Traite  Prat.  d'Anat.  Med.-Chirurg.    4th  ed.,  Paris,  1873. 

3  Op.  cit. ,  p.  103. 


21S 


DISEASES    OF    THE    EECTT7M    AND    ANUS. 


with  jelly-like  substance,  the  name  myxoma  lias  also  been  ap- 
plied. 

These  hard  or  fibrous  polypi  vary  greatly  in  their  degrees  of 
hardness  to  the  feel,  according  to  their  turgescence  and  their 
composition.  They  may  creak  under  the  knife  on  section,  and 
look  very  much  like  hypertrophied  and  oedematous  skin,  or 
they  may  resemble  the  better-known  nasal  polypus  in  their 
consistence. 

The  connective-tissue  fibres  are  generally  irregularly  dis- 
posed, and  cross  each  other  in  every  direction,  though  a  regular 


r*>     ,*"^'V: 


TT  ».?  '  T  f  T  f  I  T  I  T  '  *   '   '  T 


'?^M 


^^(C2rj»J 


Fig.  72— Vertical  Section  of  Glandular  Polypus.     (Esmarch.) 

stratification,  such  as  is  seen  in  uterine  myxomata,  may  be 
present  (Esmarch).  When  seen  in  the  rectum  before  removal, 
the  surface  is  generally  red  from  their  vascularity;  but  after  re- 
moval they  are  pale,  and  generally  smooth,  though  sometimes 
uneven  and  irregular  in  surface,  and  covered  with  hypertrophied 
papilla?.  The  mucous  membrane  is  generally  easily  stripped  off, 
though  if  there  has  been  local  inflammatory  irritation  it  maybe 
firmly  attached.  The  vascular  supply  is  abundant,  and  dis- 
tributed both  to  the  substance  and  surface  of  the  tumor.  This 
accounts  for  their  rapid  development. 


NON-MALIGNANT  GEOWTHS  OF  THE  EECTUM  AND  ANUS.       219 

The  pedicle  is  generally  very  slight,  and  is  formed  mechani- 
cally by  the  traction  of  the  growth  on  the  mucous  membrane 
beneath  which  it  is  located.  It  is  composed,  as  in  the  soft 
variety,  simply  of  mucous  membrane  and  blood-vessels.  There 
may,  however,  in  a  case  where  the  pedicle  has  been  formed  by 
traction  upon  and  prolapse  of  all  the  coats  of  the  bowel  by  a 
tumor  located  primarily  above  the  reflection  of  the  peritoneum, 
be  a  peritoneal  cul-de-sac  within  the  pedicle. 

An  hypertrophy  and  increased  vascularity  of  the  mucous 
membrane  at  the  attachment  of  the  pedicle  has  been  noted  in 
certain  cases. 

If  left  to  its  natural  course,  the  pedicle  gradually  becomes 
longer  and  more  slender,  and  finally  ruptures  in  the  act  of  de- 
fecation, and  in  this  way  a  patient  may  relieve  himself  of  the 
growth. 

These  tumors  are  benign  in  character,  and  when  once  re- 
moved do  not  generally  return  at  the  same  point.  They  may, 
however,  recur,  if  not  at  the  same  point,  at  one  very  near  it, 
and  the  same  patient  may  be  relieved  of  a  succession  of  them. 

Quite  recently  I  was  called  upon  to  remove  three  of  these 
growths  from  the  rectum  of  a  brother  practitioner,  in  whom 
t\\Qj  had  been  growing  nearly  twenty  years.  At  each  act  of 
defecation  two  of  them  were  protruded,  one  the  size  of  a  hen  s 
egg  and  the  other  not  much  smaller.  They  were  hard  to  the 
touch,  very  painful  when  handled,  perfectly  white,  and  with- 
out an}^  trace  of  vascularity  on  the  surface,  and  attached  by 
large  and  strong  pedicles,  one  on  each  side  of  the  rectum,  about 
an  inch  above  the  anus.  The  third  one  was  much  smaller,  and 
was  attached  posteriorly.  Under  the  microscope  they  were 
found  to  consist  chiefly  of  fibrous  tissue  arranged  irregularly, 
though  in  parts  the  sarcomatous  element  was  well  marked. 
The  mucous  membrane  which  originally  covered  them  had  en- 
tirely disappeared,  though  they  were  described  as  having  at  one 
time  been  very  vascular  on  the  surface — so  much  so  that  when 
extruded  in  defecation  the  blood  spirted  from  little  papillae  in 
numerous  jets. 

Symptoms. — A  rectal  polypus  may  exist  for  many  years, 
and  give  no  sign  of  its  presence.  The  two  chief  symptoms 
which  it  is  apt  to  excite  are  haemorrhage  and  discharge.  The 
haemorrhage  may  be  a  daily  occurrence,  or  may  be  present  only 
at  long  intervals,  and  it  may  vary  in  amount  from  a  few  drops 


220  DISEASES    OF    THE    RECTUM    AND    ANUS. 

to  a  quantity  which  shall  cause  grave  disturbance  and  alarm. 
When  the  mucous  membrane  covering  the  tumor  has  once  be- 
come ulcerated,  the  haemorrhage  will  be  frequent,  and  the  dis- 
charge will  be  more  or  less  fetid.  The  vessels  are  apt  to  bleed 
freely  when  opened,  because  of  their  being  embedded  in  fibrous 
tissue,  and  of  their  inability  to  contract.  When  the  tumor  is  so 
high  and  the  pedicle  so  short  as  to  be  beyond  the  grasp  of  the 
sphincter,  there  is  no  suffering  ;  but  after  prolapse  once  begins 
to  take  place,  the  suffering  may  be  very  severe.  The  sphincter 
may  become  dilated  and  relaxed,  or  the  pedicle  may  be  firmly 
grasped  by  it  after  the  act  of  defecation,  and  a  cure  may  result 
from  the  strangulation  thus  caused. 

The  discharge  from  the  rectum  which  a  polypus  may  cause 
is  sometimes  extreme  in  amount  and  constant,  escaping  not 
only  at  the  time  of  defecation,  but  at  frequent  intervals  be- 
tween, and  being  of  an  excessively  fetid  character.  This  dis- 
charge may,  by  its  irritating  qualities,  cause  secondary  conges- 
tion of  the  rectal  mucous  membrane,  erosions  around  the  anus, 
vegetations,  constant  diarrhoea,  and  tenesmus ;  and,  joined 
with  the  loss  of  blood,  the  condition  of  the  patient  may  be 
easily  mistaken  for  that  of  chronic  dysentery  or  even  malignant 
disease. 

There  are  several  points  worthy  of  attention  in  examining  a 
patient  for  this  disease.  It  is  a  good  plan,  as  suggested  by 
Chassaignac,  to  first  administer  an  enema  of  water  before  mak- 
ing the  examination,  that  the  polypus  may  float  freely  in  the 
distended  rectum.  The  finger  is,  in  the  vast  majority  of  cases, 
all  that  is  necessary  for  the  examination  ;  and  as  Molliere  sug- 
gests, the  examination  should  be  made  from  above  downward, 
and  not,  as  is  usually  the  case,  from  below  upward.  In  the 
former  case,  by  passing  the  finger  up  along  the  anterior  wall 
and  withdrawing  it  along  the  posterior,  the  tumor  may  easily 
be  caught  in  the  descent  after  the  pedicle  has  been  put  upon 
the  stretch,  while  in  the  latter  case  it  may  easily  be  carried  up 
the  bowel  and  escape  detection  altogether. 

Diagnosis. — Haemorrhage  from  the  rectum  in  a  child,  with 
or  without  pain  on  defecation,  generally  means  polypus  ;  and 
it  often  means  the  same  in  an  adult,  though  it  will  oftener  in- 
dicate haemorrhoids.  The  secondary  symptoms,  which  seem  to 
point  to  dysentery,  must  never  cause  the  original  disease  to  be 
overlooked.     There  is,  in  fact,  but  little  difficulty  in  the  diag- 


NON-MAUGWANT  GROWTHS  OF  THE  RECTUM  AND  AXES.       221 

nosis  of  a  polypus  in  the  vast  majority  of  cases  ;  but  once  in  a 
■while,  where  the  attachment  is  broad  and  the  pedicle  not  well 
marked,  the  question  of  benign  or  malignant  growth  may  arise 
and  be  difficult  to  solve  except  by  the  subsequent  history  and 
development  of  the  case. 

In  the  chapter  on  cancer  attention  will  be  called  to  the  fact 
that  the  distinction  between  epithelioma  and  a  benign  polypus 
of  the  adenoid  variety  cannot  always  be  made  by  the  micro- 
scopic examination  ;  and  we  here  emphasize  the  fact  that  the 
diagnosis  must  rest  rather  upon  the  clinical  history  and  gross 
appearances  than  upon  histological  iDvestigation  of  the  growth 
when  removed.  In  children  malignant  disease  is  so  rare  that 
the  chances  are  greatly  in  favor  of  benignity.  Malignant 
growths,  moreover,  do  not  tend  to  spontaneous  extrusion,  and 
are  not  pedunculated,  and  the  presence  of  a  pedicle  is  therefore 
greatly  in  favor  of  benignity.  Bat  given  an  adult  with  an 
adenoid  polypus  which  has  ulcerated,  and  which  is  not  pedun- 
culated, and  the  diagnosis  between  it  and  malignant  disease 
may  be  impossible,  either  by  the  microscope  or  the  clinical 
history  ;  for  the  ulcerated  and  bleeding  tumor  may  cause  a 
wasting  and  cachexia  which  strongly  resembles  cancer.  A  soft 
polypus  may  also  be  mistaken  for  an  internal  hsernorrhoid  when 
no  pedicle  is  present,  but  the  point  of  attachment  is  different  in 
the  two  cases. 

Treatment. — The  treatment  of  polypi  is  generally  a  simple 
matter,  and  consists  in  their  extirpation,  after  which  they 
rarely  return.  There  are  two  dangers  to  be  considered ;  the 
first  is  that  the  pedicle,  when  a  pedicle  exists,  may  contain 
large  vessels ;  the  other  is  that  it  may  contain  peritoneum. 
The  extirpation  of  a  polypus,  which  has  come  down  from  its 
attachment  in  the  sigmoid  flexure,  has  been  followed  by  death 
from  wounding  the  peritoneum,  at  the  hands  of  no  less  a  sur- 
geon than  Broca.  "Where  the  pedicle  is  long  and  slender,  the 
polypus  may  generally  be  twisted  off  by  simple  torsion  without 
danger.  It  is  generally  safer,  however,  first  to  apply  a  ligature, 
and  then  cut  away  the  tumor.  Should  there  be  no  pedicle,  the 
mass  must  be  extirpated  as  any  tumor  would  be,  and  the 
haemorrhage  which  occurs  must  be  treated  upon  general  sur- 
gical principles. 

Vegetations. — These  growths,  known  also  by  the  names  of 
warts  and  papillomata,  may  be  denned  histologically  as  an  hy- 


222 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


pertrophy  of  the  papillary  layer  of  the  skin  and  of  the  papillary 
layer  only.  They  are  composed  of  the  connective  tissue,  the 
epithelial  covering,  and  the  blood-vessels,  which,  in  their  natural 
quantities,  form  the  papillae  of  the  derma. 

The  gross  appearances  of  these  warty  growths  are  repre- 
sented in  Fig.  73. 


PlG.  73. — Vegetations.     (Esmarch.) 

Under  the  influence  of  any  of  the  exciting  causes  which  will 
soon  be  mentioned,  little  tumors  resembling  ordinary  warts  ap- 
pear, and  grow  rapidly  till  they  reach  two  or  three  millimetres 
in  size.  The  extremity  of  the  tumor  shows  a  decided  tendency 
to  branching  and  bifurcation,  and  when  there  are  many  of  them 
their  branching  extremities  may  fuse  together  and  form  a  large 


NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS.       223 

flat  tumor,  which  will  be  attached  to  the  skin,  however,  by 
numerous  little  pedicles,  so  that,  if  shaved  off,  the  skin  will  not 
be  wounded  except  in  numerous  small  points  where  the  pedicles 
have  had  each  its  independent  attachment. 

When  the  wart  is  isolated  it  is  dry,  but  when  several  are 
united  they  become  macerated  in  the  secretion  of  the  part,  which 
decomposes  between  them  and  gives  rise  to  inflammatory  phe- 
nomena. The  tumor  then  becomes  moist  and  fetid,  and  all  the 
adjacent  parts  become  irritated.  According  to  the  size  of  the 
growths,  the  condition  of  the  patient,  the  abundance  of  the  se- 
cretions, and  the  irritation  to  which  they  are  originally  due, 
these  vegetations  take  on  various  shapes,  and  have  been  de- 
scribed as  cock's- combs,  cauliflower  excrescences,  etc.,  etc. ;  but 
the  elementary  structure  of  them  all  is  the  same — an  hyper- 
trophy and  branching  of  the  papillae  of  the  derma. 

On  placing  a  longitudinal  section  of  one  of  these  warts  under 
the  microscope  the  following  structures  will  be  seen.  In  the 
centre,  a  framework  of  connective  tissue  composed  of  a  pro- 
longation of  the  papillary  bodies  of  the  derma  ;  in  the  centre  of 
this  a  vascular  loop  ;  the  whole  covered  by  one  or  more  layers 
of  epithelium,  the  form  and  size  of  which  are  variable,  and  de- 
pend apparently  on  several  conditions,  such  as  the  moisture  and 
dryness  of  the  parts,  and  the  amount  of  pressure  to  which  the 
growths  are  subject.  When  the  connective  tissue  is  abundant 
and  the  epithelial  layer  relatively  thin,  the  vegetations  are  dry 
and  hard.  When  the  conditions  are  reversed,  they  are  moist. 
When  the  vascular  network  is  greatly  developed,  the  tumors  are 
red  and  turgescent,  and  bleed  easily. 

The  growth  occurs  from  the  cells  of  the  proliferating  zone, 
between  the  summit  of  the  papilla  and  the  epithelial  covering. 
The  intercellular  substance  of  the  connective  tissue  becomes  less 
abundant,  while  the  cellular  elements  increase,  and  mingle  above 
with  the  epithelial  layer,  and  below  with  the  connective  tissue. 
Similar  proliferating  zones  may  be  seen  on  the  lateral  surfaces 
of  the  ramifying  warts,  and,  through  their  medium,  the  ramifi- 
cations develop  at  the  extremity  of  the  wart,  while  on  the  level 
with  the  proliferating  zones,  the  capillary  loops  grow  and  de- 
velop by  which  the  afferent  and  efferent  vessels  communicate 
(Rindfleisch,  Molliere). 

These  vegetations  were  formerly  considered  as  proof  positive 
of  the  existence  of  syphilis,  and  even  of  sodomy,  and  were 


224  DISEASES    OF   THE    RECTUM    AND    ANUS. 

treated  as  such.  Molliere '  relates  how,  at  the  time  of  Dionysius, 
there  was  a  special  hospital  at  Rome  for  the  treatment  of  these 
growths  ;  and  Dionj'sius  himself  tells  how  the  surgeons  spared 
neither  the  iron  nor  the  fire,  and  were  not  moved  to  pity  by  the 
cries  of  the  patients,  inasmuch  as  this  disease  was  the  result  of 
unnatural  intercourse  between  man  and  man. 

The  same  false  idea  has  lasted  until  the  present  time,  and  is 
even  now  far  from  unpopular  ;  and  yet  the  independence  of 
these  growths  upon  syphilis  would  seem  to  be  beyond  question, 
except  to  the  extent  that  any  syphilitic  sore  in  this  neighbor- 
hood may,  by  the  irritation  of  its  discharge,  cause  their  pro- 
duction. They  owe  their  growth,  in  the  first  place,  as  pointed 
out  by  Diday,3  to  a  special  predisposition  to  the  formation  of 
wart}^  growths  on  various  parts  of  the  body  in  the  individual, 
and  this  predisposition  is  assisted  by  the  presence  of  any  irrita- 
tion of  the  part.  Thus  the  discharge  from  a  gonorrhoea  or  a 
leucorrhcea,  or  any  disease  of  the  rectum  or  genitals,  may 
cause  them  to  grow,  and  they  may  appear  in  persons  appar- 
ently perfectly  healthy  and  cleanly.  Pregnancy  has  an  un- 
doubted influence  upon  their  production,  and  they  sometimes 
disappear  spontaneously  after  delivery.  From  what  has  been 
said,  it  is  evident  that  these  growths  are  neither  contagious  nor 
inoculable,  and  that  anti-syphilitic  treatment  can  be  of  no  avail. 

Symptoms. — These  vegetations  may  occur  at  any  age  from 
infancy  to  adult  life,  though  they  generally  belong  to  the  latter 
period.  They  may  vary  in  size  and  quantity  from  a  single  en- 
larged papilla  at  the  verge  of  the  anus  to  a  mass  such  as  is  rep- 
resented in  the  plate,  and  which  weighs  as  much  as  a  pound. 
The  symptoms,  in  any  case,  will  vary  with  their  size,  number, 
location,  and  the  amount  of  the  secretion.  When  they  grow 
from  one  side  of  the  intergluteal  fold,  and  are  large  enough  to 
press  with  their  moistened  surface  upon  the  corresponding 
point  of  the  opposite  side,  a  second  patch  may  be  developed  at 
the  point  of  contact.  The  irritation  from  any  other  source 
would  have  the  same  effect.  The  development  of  the  growths 
may  be  slow  or  rapid,  and  when  the  tumors  are  of  large  size, 
the  patient  is  constantly  troubled  by  the  feeling  of  a  foreign 
body,  by  a  sanious  and  foul-smelling  discharge,  and  by  fresh 
erosions  and  superficial  ulcers  in  the  adjacent  parts.      Great 

'Op.  cit.,  p.  506. 

5  Exposition  critique  et  pratique  des  uouvelle3  doctrines  sur  la  syphilis.  Paris,  1858. 


NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS.       225 

pain  in  defecation  may  be  produced  by  a  small  wart  situated 
just  at  the  verge  of  the  anus,  and  such  a  little  tumor  may  give 
rise  to  all  the  characteristic  symptoms  of  a  painful  fissure,  in- 
cluding a  slight  discharge,  and  an  occasional  drop  or  two  of 
blood.  They  are  not  very  infrequent  on  the  line  of  junction  of 
the  mucous  and  cutaneous  surfaces,  just  within  the  verge  of  the 
anus.  They  may,  also,  spring  entirely  from  the  mucous  mem- 
brane, above  the  sphincter,  though  they  are  generally  confined 
to  the  first  inch  of  the  canal,  and,  in  such  cases,  give  rise  to  a 
much  more  aggravated  train  of  symptoms,  and  to  much  dif- 
ficulty of  diagnosis.  There  they  are  generally  smaller  and 
harder  than  when  on  the  cutaneous  surface,  and  cause  a  serous 
discharge,  which  may  be  so  profuse  as  to  escape  from  the  anus 
between  the  acts  of  defecation,  and  cause  much  suffering  from 
pruritus  and  rectal  tenesmus. 

On  examination  in  such  a  case  the  mucous  membrane  will 
be  found  dry  and  glistening,  as  a  rule,  though  sometimes  there 
may  be  a  more  or  less  extensive  proctitis  ;  and  the  little,  hard, 
tender,  warty  excrescence,  which  is  the  cause  of  all  the  grave 
train  of  symptoms  and  of  so  much  suffering,  may  easily  escape 
detection.  The  only  treatment  for  such  a  condition  is  to  seize 
the  little  tumor  with  the  toothed  forceps,  and  excise  the  mu- 
cous membrane  to  which  it  is  attached.  It  may,  however,  re- 
turn many  times.1 

Diagnosis. — The  diagnosis  of  these  growths  is  not  generally 
difficult,  though  care  is  necessary  when  they  are  small  and 
located  within  the  grasp  of  the  sphincters.  The  mistake  most 
commonly  made  is  to  consider  them  as  syphilitic  condylomata  ; 
and,  indeed,  they  may  not  always  be  easily  distinguishable  from 
the  raised  mucous  patch  or  flat  condyloma  which  is  a  manifesta- 
tion of  true  syphilis.  A  careful  examination  of  a  raised  mucous 
patch  can  scarcely  fail,  however,  to  show  the  difference  between 
its  general  character  and  that  of  a  cauliflower  growth  which  has 
sprung  up  from  the  surface  like  a  shrub,  and  is  attached  to  it 
by  numerous  little  pedicles.  The  two  may  exist  simultaneously, 
the  wart  being  caused  by  the  irritation  of  the  discharge  from 
the  other.  There  is  little  danger  of  mistaking  these  vegetations 
for  malignant  growths,  though  they  have  been  known  to  assume 
a  semi-malignant  epithelial  character,  and  to  return  frequently 
after  removal. 

1  Des  Verrues  de  l'intestiu  rectum.     Rognetta,  Gaz.  med.  de  Paris,  June,  1835. 
15 


226  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Treatment. — The  surest,  most  rapid,  and  in  every  way  most 
satisfactory  way  of  curing  these  vegetations  is  by  simple  ex- 
cision with  the  knife  or  scissors.  The  ligature  is  often  inap- 
plicable, and  cauterization  is  not  always  easy  to  limit  in  its 
action.  The  growths  may,  however,  often  be  induced  to  dry 
and  shrink  up  by  applications  of  powdered  alum  or  tannin, 
and  by  washing  with  astringent  lotions,  such  as  Labarraque's 
solution. 

Condylomata. — The  term  condyloma  has  been  applied  to 
many  different  growths  around  the  anus,  as  well  as  to  the 
raised  mucous  patch  already  spoken  of,  and  to  the  remains  of 
external  haemorrhoids.  It  will  be  used  here  to  refer  to  the  non- 
syphilitic  growths  of  skin  frequently  seen  around  the  anus, 
which  are  attached  by  a  broad  base,  are  pinkish  in  color,  soft, 
fleshy,  glistening,  moist,  and  irregular  in  shape,  flattened  where 
two  are  pressed  together,  or  where  one  is  subjected  to  the  press- 
ure of  the  buttocks,  and  which  generally  give  out  a  slight  se- 
cretion. 

They  generally  have  one  of  the  radiating  folds  of  the  anus 
as  their  point  of  departure,  and  they  differ  from  the  class  of 
vegetations  last  described  in  that  they  consist  of  an  hyper- 
trophy of  the  whole  thickness  of  the  skin,  and  not  alone  of  the 
papillae.  The  epithelial  element  in  them  is  not  as  marked  as  in 
the  warts,  and  the  blood-vessels  are  also  less  developed.  They 
are  merely  the  result  of  a  localized  chronic  inflammation  and 
thickening  of  the  skin,  and  often  follow  an  external  haemorrhoid 
or  any  local  irritation  such  as  has  been  spoken  of  in  connection 
with  vegetations.  They  are  generally  isolated  and  few  in 
number  ;  but  it  may  happen  that  after  the  irritation  to  which 
they  owe  their  origin  has  ceased,  the  growth  may  continue, 
becoming  harder  and  more  movable,  and  resembling  a  true 
fibroma.  Such  a  hard  tumor  may,  under  sufficient  irritation, 
take  on  an  ulcerative  and  suppurative  action,  its  size  all  the 
while  increasing,  until  a  foul,  painful,  indurated  mass  results 
which  strongly  resembles  malignant  disease.  Paget '  once  said 
that  without  considering  these  growths  as  absolutely  and  al- 
ways syphilitic,  they  are  so  rare  without  it,  that,  as  yet,  he  had 
not  seen  a  case.  They  are  a  very  common  accompaniment  of 
any  ulcerative  process  within  the  rectum,  and  hence  of  stricture, 
and  many  a  stricture  has  been  untruly  stamped  as  syphilitic 

1  Medical  Times  and  Gazette,  vol.  i.,  1865,  p.  279. 


NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS.       227 

because  the  discbarge  from  the  anus  had  caused  a  development 
of  these  fleshy  tags.  They  are  indeed  common  in  syphilis  of 
this  part,  but  they  are  not  syphilitic. 

These  condylomatous  tumors  occasionally  reach  a  large  size, 
as  in  a  case  recently  reported  by  Dr.  Barnes.1  The  tumor  in 
his  case  was  the  size  of  an  ordinary  orange,  and  had  been  pro- 
truded from  the  anus  during  labor.  It  proved  to  be  a  dense 
growth  attached  to  the  margin  of  the  anus,  the  rest  of  the  anal 
circumference  being  surrounded  by  piles  more  or  less  indurated. 
At  one  point  the  tumor  was  greenish,  as  if  about  to  sphacelate. 
It  was  removed  by  galvano-cautery.  It  had  a  broad  base,  and 
Dr.  Barnes  looked  upon  it  as  an  outgrowth  from  a  hsemor- 
rhoidal  tumor.  Dr.  G-oodhart  reported  it  as,  for  the  most  part, 
composed  of  loose  fibro- cellular  tissue,  covered  by  a  tough  and 
altered  mucous  membrane  ;  the  deep  parts  were,  however, 
cavernous  in  structure.  He  was  of  opinion  that  it  originated  in 
some  chronic  overgrowth  of  connective  tissue  round  a  pile. 

The  diagnosis  of  these  growths  is  generally  easy.  They  can 
scarcely  be  mistaken  for  aught  except  a  syphilitic  gummy  de- 
posit or  malignant  disease,  and  they  are  not  apt  to  be  con- 
founded with  either.  I  have  seen  malignant  deposit,  however, 
mistaken  for  simple  condyloma,  and  treated  by  mercurials, 
ablation,  and  the  hot  iron,  it  is  needless  to  say  without  benefit. 

The  necessity  for  distinguishing  between  the  syphilitic  and 
non-syphilitic  condylomata  around  the  anus  has  already  been 
referred  to.  There  is  a  variety  of  mucous  patch  situated  upon 
the  skin  near  the  anus  which  is  often  spoken  of  as  condyloma 
lata,  or  vegetating  condyloma. 

The  syphilitic  condyloma  first  manifests  itself  as  a  red  spot 
and  by  a  slight  effusion  beneath  the  epidermis,  which  is  soon 
rubbed  off  by  friction,  exposing  a  raw  surface,  generally  covered 
by  a  grayish  pellicle.  This  surface  is  subsequently  elevated  by 
an  upward  growth,  and  by  branching  of  the  papillae,  with  for- 
mation of  connective  tissue,  and  dilatation  of  the  blood-vessels. 
Where  this  development  of  the  papillse  has  reached  a  consider- 
able extent,  the  cauliflower  appearance  is  the  result,  and  what 
was  at  first  a  simple  mucous  patch  may  become  a  large  pe- 
dunculated wart  surrounded  by  other  vegetations  which  have 
sprung  up  around  the  original  lesion,   and  which  are  due  to 


1  British  Medical  Journal,  April  12,  1879. 


228 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


the  irritation  of  its  presence  (Bumstead   and  Taylor,  Keyes, 
Baumler). 

It  may  be  impossible  to  distinguish  this  form  of  syphilis 
from  the  simple  vegetation  already  described,  except  by  the 
history,  the  fact  of  its  infectiousness,  and  the  results  of  treat- 
ment. Under  the  microscope  both  are  composed  of  an  hyper- 
trophy of  the  papillse  of  the  derma.  It  ought  not,  however,  to 
be  difficult  to  distinguish  between  this  syphilitic  mucous  patch 
and  the  simple  hypertrophy  of  the  skin,  such  as  is  seen  at  the 


Fig.  74. — Condyloma  Lata,  or  Vegetating  Condyloma.     (Bumstead  and  Taylor.) 

site  of  an  old  external  pile,  to  which  we  here  limit  the  name  of 
condyloma. 

This  loose  and  undefined  use  of  the  word  condyloma  is 
much  to  be  regretted,  but  is  so  common  as  to  make  any  change 
out  of  the  question.  It  is  used  here  to  denote  only  one  form  of 
growth,  the  simple  non-syphilitic  lrypertrophy  of  the  whole 
skin.  What  is  usually  called  the  syphilitic  condyloma  is  here 
referred  to  as  the  raised  or  vegetating  mucous  patch. 

The  only  treatment  necessary  in  cases  of  condylomata  is 
their  simple  excision,  after  which  there  will  generally  be  no 
return. 

Benign  Fungus. — Under  this  title  Molliere1  describes  a 
granular  condition  of  the  mucous  membrane  of  the  lower  end 

1  Op.  cit,  p.  524. 


NON-M  ALIGN  ANT  GROWTHS  OF  THE  RECTUM  AND  ANUS.       229 

of  the  rectum  occasionally  seen  in  children  as  a  result  of  pro- 
lapse. It  is  composed  of  soft,  friable,  vascular  tissue,  identical 
with  the  granulations  of  a  cicatrizing  wound.  The  surface  of 
the  mass  is  red  and  uneven,  the  base  is  marked  by  dilated  veins. 
After  defecation  the  tumor  may  remain  prolapsed,  but  it  is 
easily  reducible,  and  when  prolapsed  is  not  painful,  which  is  a 
distinguishing  mark  between  it  and  polypus.  The  haemorrhage 
attending  this  form  of  growth  is  always  abundant  and  may 
cause  much  wasting.  On  account  of  this  haemorrhage  the 
growth  is  best  treated  by  cauterization  and  astringents. 

Gummata. — These  also  may  affect  either  anus  or  rectum, 
though  their  rarity  in  the  latter  may  best  be  judged  by  the 
statement  of  Fournier '  that  he  has  never  seen  one,  and  only 
admits  their  existence  on  the  testimony  of  Verneuil,  who  has 
seen  one.  However,  their  presence,  a  fortiori  probable,  has 
been  demonstrated  by  other  observers  than  Verneuil.  Esmarch 2 
admits  it ;  Zeissl 3  reports  a  case  in  a  male,  and  Zappula  *  an- 
other ;  Molliere  6  has  seen  one  starting  at  the  anus  and  extend- 
ing into  the  ischio-rectal  fossa ;  and  Fournier6  himself  met  one 
in  a  young  woman  starting  in  the  left  buttock,  and  secondarily 
involving  the  anus  and  then  the  rectum. 

Ano-rectal  Syphiloma. — This  affection  is  defined  by  Four- 
nier7 as  "  an  infiltration  of  the  rectal  walls  by  neoplasm,  whose 
initial  structure  is  still  undetermined,  but  susceptible  of  degen- 
erating into  retractile  fibrous  tissue,  and  of  constituting  in  this 
way  more  or  less  extensive  intestinal  strictures."  He  speaks 
of  it  as  "hyperplastic  rectitis,  becoming  later  a  fibro-sclerous 
rectitis,"  and  as  identical,  or  at  least  analogous,  to  other  lesions 
of  the  same  order  developed  in  different  viscera,  as  the  liver  or 
testicle.  He  particularly  emphasizes  the  fact  that  this  process 
begins  in  the  submucous  layers,  and  that  the  mucous  membrane 
is  only  secondarily  destroyed,  being  at  first  entirely  free  from 
ulceration  or  cicatrices.  Its  point  of  predilection  is  the  rectal 
pouch,  but  it  may  be  found  below.  He  has  never  seen  it  above. 
Sometimes  only  two  or  three  centimetres  of  the  wall  are  in- 
volved, but  when  it  begins  at  the  anus  it  may  reach  seven  or 
eight  centimetres  up.     It  forms  a  cylinder  around  the  whole 

1  Lesions  tertiaires  de  1'Adus  et  du  Rectum,  p.  8.     Paris,  1875,  2  Op.  cit. 

3  Vrtljschr.  f.  Dermatol,  u.  Syph.,  1876,  H.  ii. 

4  Ann.  Univ.  de  Med.,  ccxiii.     Milan,  1870.  5  Op.  cit.,  p.  645. 
c  Op.  cit.                     1  Lesions  tertiaires  de  l'Anus  et  du  Rectum.    Paris,  1875. 


230  DISEASES    OF    THE    RECTUM    AND    ANUS. 

circumference  of  the  bowel.  In  the  initial  stage  the  rectum  is 
only  stiffened  and  thickened,  but  not  contracted.  When  the 
infiltration  is  limited  to  the  vicinity  of  the  anus,  it  is  not  uni- 
formly diffused  around  its  circumference,  but  forms  irregular 
masses  which  are  at  first  covered  by  healthy  tissue.  These  are 
painless  unless  inflamed,  but  are  liable  to  erosion  and  ulcera- 
tion. The  disease  is  more  common  in  females  than  in  males — 
eight  to  one. 

Unfortunately  the  specific  character  of  this  ulceration  cannot 
be  proved  under  the  microscope,  there  being  nothing  distinctive 
in  its  structure.  The  theory  advanced  by  Fournier  has  held  its 
own,  however,  and  has  gained  adherents.  Duplay1  adopts  it, 
and  Van  Buren  has  distinctly  recognized  this  form  of  disease, 
and  has  also  "  seen  it  disappear  under  anti-syphilitic  treat- 
ment," though  Fournier  says  distinctly  the  anti-syphilitic 
treatment  exercises  no  curative  influence  on  confirmed  syphilitic 
retraction,  and  this  he  explains  on  the  ground  that  the  contrac- 
tion is  less  a  syphilitic  lesion  than  the  ultimate  consequence  of 
a  syphilitic  lesion,  just  as  a  cicatrix  is  the  ultimate  consequence 
of  a  wound. 

The  remainiug  tumors  which  occur  in  this  part  of  the  body 
are  very  rare,  so  rare  as  to  be  rather  curiosities  than  otherwise  ; 
and  yet,  as  they  may  be  met  with  at  any  time,  it  will  not  be  a 
waste  of  time  to  enumerate  them  and  say  a  few  words  concern- 
ing each  in  turn. 

Fibromata. — True  fibrous  tumors  may  develop  outside  of 
the  anus.  Curling2  gives  a  description  of  one  such  case  re- 
moved by  Mr.  Hovel,  of  Clapton,  which  had  been  growing  for 
seven  years  and  weighed  upward  of  half  a  pound.  It  was 
composed  of  fibrous  tissue  arranged  in  several  lobes,  was  pen- 
dulous and  attached  to  the  margin  of  the  anus  by  a  narrow 
neck.  The  surface  was  ulcerated  from  friction.  He  remarks 
that  they  seldom  exceed  the  size  of  a  chestnut,  and  that  their 
surface  is  generally  irregularly  lobulated. 

Lipomata. — Of  these  fatty  tumors  there  are  only  a  few 
scattered  cases  in  literature  from  which  to  derive  a  general 
knowledge  of  their  characteristics  in  this  part  of  the  body. 
Esmarch'  speaks  of  two  cases,  one  observed  by  Weiss,  the  other 
by  Bose.     The  former  occurred  in  the  surgical  clinic  at  Prague, 

1  Le  Progrea  Med.,  Novembre  30,  1876.      »  Op.  cit.,  p.  188.      3  Op.  cit,  p.  154. 


NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS.       231 

its  size  was  that  of  a  plum,  and  it  had  caused  an  invagination  of 
the  sigmoid  flexure  into  the  rectum  and  a  prolapse  nearly  four 
inches  in  length.  After  extirpation  of  the  tumor  and  ligature 
of  the  pedicle,  the  prolapse  was  reduced  and  the  invagination 
overcome  by  forced  injections.  The  second  case  was  somewhat 
similar  and  occurred  in  Langenbeck's  clinic.  Molliere '  gives 
two  cases  in  full.  One  from  CI.  Bernard2  in  a  woman  eighty- 
three  years  of  age,  who  complained  of  obstinate  constipation 
and  dyspepsia,  and  a  sensation  as  if  of  the  weight  of  a  foreign 
body  in  the  rectum.  By  making  a  digital  examination  upon 
herself  she  could  feel  the  tumor,  and  she  soon  succeeded  in 
evacuating  it.  It  weighed  twenty  grammes,  was  about  the  size 
of  a  pigeon's  egg,  was  composed  entirely  of  fat,  and  had  a  dis- 
tinct and  slender  pedicle.  The  other  case, 3  reported  by  Castilain, 
occurred  in  a  man  aged  forty-three,  who  complained  of  the 
same  symptoms  of  constipation  and  dyspepsia,  and  this  also 
was  expelled  spontaneously  by  the  straining  of  the  patient. 
The  doctor  at  first  supposed  the  mass  to  be  a  ball  of  hardened 
faeces,  but  a  closer  examination  proved  it  to  be  an  ovoidal 
tumor  measuring  twelve  centimetres  in  length  by  six  in  thick- 
ness. The  consistence  was  firm,  and  the  section  reddish  in 
color.  The  tumor  showed  numerous  lobules  and  was  enveloped 
in  a  resisting  envelope.  At  one  end  there  was  a  distinct  pedicle 
two  or  three  centimetres  long,  and  slender.  Spencer  Wells 4  has 
also  reported  a  large  lobulated  fatty  tumor,  weighing  two 
pounds,  which  he  removed  from  the  recto-vaginal  septum. 

Fatty  tumors  may  also  occur  in  the  region  around  the  anus 
and  encroach  upon  it  to  a  greater  or  less  extent.  Molk,5  in  his 
well-known  thesis,  gives  several  such  examples.  They  may  be 
divided  into  the  pedunculated  and  non-pedunculated.  The 
former  occurs  especially  in  children,  and  are  easily  removed  by 
knife,  scissors,  or  galvano-cautery  wire,  and  generally  without 
great  danger.  The  non-pedunculated  variety  is  much  rarer. 
Molk  relates  one,  in  a  still-born  child,  which  filled  the  pelvis, 

1  Op.  cit. ,  p.  525  et  seq. 

2  Azefou :  Bull,  de  la  Soc.  anatomique,  seance  du  Mars  26,  1875. 

3  Gaz.   hebdomadaire,   Mai,  1870,  p.    318,  et  Bull.  Med.  du  Nord  de  la  France, 
Mars,  1870. 

*  Transactions  London  Pathological  Society,  vol.  xvi. ,  p.  277. 

5  Des  tumeurs  congenitales  de  l'extremite  intVrieur  du  tronc.     These  de  Stras- 
bourg, 1868,  No.  106. 


232  DISEASES    OF    THE    RECTUM    AND    ANUS. 

and  descended  to  the  calves  of  the  legs.  Robert '  has  recorded 
another  in  which  the  tumor  sprang  from  the  ischio-rectal  fossa, 
and  was  at  first  mistaken  for  a  perineal  hernia.  It  occurred 
in  a  riding-master,  forty-five  years  of  age,  and  measured  ten 
centimetres  by  seven.  The  operation  at  first  consisted  in  cut- 
ting down  upon  the  tumor,  layer  by  layer,  as  in  the  case  of  a 
hernia  ;  but  as  soon  as  its  true  nature  was  evident  it  was  fol- 
lowed into  the  ischio-rectal  fossa  and  extirpated.  The  patient 
was  well  in  a  fortnight. 

Virchow2  has  made  a  study  of  these  intestinal  fatty  tumors 
from  which  the  following  general  facts  may  be  derived.  The 
fatty  tissue  of  which  they  are  composed  is  apt  to  undergo  in- 
flammatory' changes  by  which  the  general  appearance  of  the 
tumor  is  changed,  so  that  when  it  appears  at  the  anus  it  may 
seem  like  a  hard  fleshy  tumor  of  dark-red  color  on  section. 
Another  result  of  the  irritation  to  which  they  are  exposed  is  the 
formation  of  a  hard  crust  on  their  surface,  which  may  finally 
become  cartilaginous  and  cause  them  to  be  confounded  with 
faecal  calculi.  Instead  of  an  inflammatory  hardening,  a  central 
softening  may  occur,  and  a  cavity  be  formed  containing  free 
liquid  fat.  Cretaceous  masses  may  also  be  found  in  the  centre 
of  the  tumors. 

In  general  these  tumors  are  attached  high  up  the  bowel, 
and  hence  the  pedicle  may  contain  peritoneum.  They  are  very 
apt  to  cause  invagination,  as  in  Esmarch's  case,  and  this  coinci- 
dence should  always  be  borne  in  mind  when  one  is  found  pre- 
senting at  the  anus. 

Enchondroma. — Cartilaginous  tumors  of  the  rectum  proper 
are  of  exceeding  rarity,  and  when  found  they  are  generally  the 
result  of  a  secondary  change  in  a  tumor  primarily  glandular, 
and  do  not  therefore  present  the  well-known  characteristics  of 
the  typical  enchondroma.  M.  Dolbeau  has  reported 3  a  case  of 
enchondroma  of  the  lower  part  of  the  rectum,  removed  from  a 
young  man  aged  twenty- seven.  The  tumor  was  the  size  of  a 
hazel-nut,  was  hard  and  movable,  and  located  at  the  entrance 
of  the  anus,  where  it  caused  no  pain  except  when  a  sound  or 
syringe  was  used.     Around  the  tumor  the  mucous  membrane 

1  Lipome  de  l'anus  simulant  une  hernie  pcrinc-ale.  Annales  de  therapeutique, 
Octobre,  1844. 

2  Pathologie  des  Tumeurs,  Translation  par  Aronssohn,  vol.  i.,  chap.  14. 

3  Bull,  de  la  Soc.  Anat.,  second  series,  t.  v.,  p.  6. 


NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS.       233 

was  eroded.  The  microscopic  examination  showed  a  predomi- 
nance of  the  fibro-cartilaginous  element  with  glandular  culs-de- 
sac,  in  the  proportion  of  one  to  four.  M.  Dolbeau  did  not 
believe  that  the  tumor  was  developed  from  the  glands  of  the  rec- 
tum, and  Robin  thought  that  the  glandular  elements  of  the 
tumor  were  of  new  formation. 

Cysts. — Cysts  in  the  neighborhood  of  the  rectum  and  anus 
may  be  of  many  varieties.  Of  the  dermoid  there  are  several 
recorded  examples.  At  a  meeting  of  the  London  Pathological 
Society,  May  18,  1880,  Dr.  Port1  showed  a  tumor  he  had  re- 
moved from  the  rectum  of  a  girl  aged  sixteen.  It  was  mainly 
composed  of  fibrous  tissue  inclosed  in  an  integument  like  ordi- 
nary skin,  covered  with  long  hair,  and  containing  abundant  in- 
voluntary fibre  like  that  seen  in  the  normal  cutis.  Growing 
upon  it  also  was  a  well-developed  canine  tooth.  The  author 
refers  to  a  somewhat  similar  case,  recently  reported  in  Ger- 
many, in  which  the  tumor  contained  not  only  a  tooth  but  brain 
substance. 

Danzell2  reports  a  case  in  a  woman,  aged  twenty- five  years, 
in  whom  a  lock  of  brown  hair,  the  size  of  the  finger,  protruded 
from  the  anus  occasionally  after  defecation.  In  the  front  wall 
of  the  rectum,  about  two  and  a  half  inches  from  the  anus,  a 
hard  tumor  could  be  felt  about  the  size  of  a  small  apple.  This 
was  extirpated  by  introducing  the  whole  hand  into  the  rectum, 
after  Simon' s  method,  death  following  some  months  after  from 
localized  peritonitis. 

The  hair  growing  from  this  tumor  was  from  twelve  to  eigh- 
teen centimetres  long.  The  tumor  itself,  when  extirpated, 
measured  4.5  ctm.  in  length,  4  ctm.  in  breadth,  and  3.5  ctm.  in 
thickness,  and  the  microscopic  examination  showed  the  usual 
cyst- wall  and  contents. 

Perrin 3  gives  an  account  of  three  cases  of  these  tumors, 
which  may  be  briefly  extracted. 

Case.  Congenital  Tumor. — Woman,  aged  thirty  years. 
First  noticed  small  tumor  at  point  of  coccyx  a  few  months  after 
confinement.  Tumor  round,  elastic,  well  defined,  firmly  adher- 
ent to  point  of  coccyx,  painless  to  the  touch,  but  more  sensitive 

1  British  Medical  Journal,  May  29,  1830,  p.  811. 

2  Geschwulst  mit  Haaren  im  Rectum.     Arch,  fiir  Clin.  Chirurg.,  1874,  p.  442. 

3  De  la  Glande  coccygienne  et  dea  tumeura  dont  elle  peut  ctre  le  siege.  Stras- 
bourg, 1860,  These  No.  530. 


234  DISEASES    OF    THE    KECTUM    AND    ANUS. 

at  menstrual  epochs,  and  when  the  patient  was  in  sitting  pos- 
ture. At  this  time  it  was  the  size  of  a  small  nut,  but  a  year 
later  it  had  increased  considerably,  and  extended  from  the  anus 
to  the  sacrum  ;  it  gave  a  sense  of  fluctuation  to  the  touch,  and 
was  unattached  to  the  skin.  Defecation  painful.  The  sac  of 
the  tumor  was  extirpated,  after  its  steatomatosis  contents  were 
emptied,  without  difficulty.  It  was  adherent  by  fibrous  tissue 
to  the  point  of  the  coccyx,  but  not  elsewhere.  The  examination 
after  removal  showed  it  to  be  about  the  size  of  a  hen's  egg,  with 
the  large  extremity  turned  toward  the  anus.  It  was  composed 
of  an  envelope  and  contents.  The  envelope  was  composed  of 
two  distinct  layers  ;  the  outer,  fibrous  and  elastic,  and  showing 
the  elements  of  cellular  tissue  under  the  microscope ;  the  inner, 
thin,  transparent,  and  resembling  a  very  thin  layer  of  cartilage. 
Under  the  microscope  this  transparent  layer  was  composed  of 
flattened,  transparent,  polygonal  epithelial  cells  about  one-for- 
tieth mm.  in  diameter. 

The  contents  of  the  sac  consisted  of  whitish  matter,  dis- 
posed in  layers  at  the  circumference,  but  mingled  in  a  tallowy 
mass  in  the  centre  ;  seen  under  the  microscope  to  be  composed 
of  epithelial  cells  filled  with  fatty  matter.     Cure. 

Case.  Congenital  Tumor. — Woman,  aged  twenty-seven 
years.  This  tumor  had  been  growing  for  five  years.  It  first 
appeared  as  a  small  tubercle  about  one-third  of  an  inch  in  size, 
very  hard  and  painless,  at  the  left  side  of  the  coccyx.  For  the 
first  three  years  it  was  painless,  but  during  the  latter  two  had 
caused  more  uneasiness  when  struck  or  pressed  upon.  After  a 
time  the  pain  was  increased,  and  became  continuous,  with  re- 
missions and  exacerbations,  and  the  size  began  to  increase, 
while  the  surrounding  parts  took  on  an  inflammatory  action. 
The  pain  followed  the  course  of-  the  sciatic  nerve  on  the  side  of 
the  tumor,  and  after  a  while  it  became  impossible  to  lie  on  the 
back  or  to  walk.  At  this  time  the  tumor  had  increased  to  the 
size  of  a  child's  fist,  and  rested  on  the  left  sacro-sciatic  liga- 
ment. The  skin  and  subcutaneous  tissue  over  it  were  healthy 
and  not  adherent.  The  tumor  itself  was  hard  and  somewhat 
elastic,  and  adherent  to  the  subjacent  parts. 

The  tumor  having  been  completely  separated  by  enucleation 
and  dissection  from  surrounding  parts,  was  cut  away  with 
curved  scissors,  care  being  taken  to  cut  the  osseous  portion  as 
much  as  possible  in  a  longitudinal  direction.     The  excised  por- 


NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS.       235 

tion  presented  a  fibrous  shell,  like  that  of  a  cyst,  containing  in 
its  upper  part  a  caseous,  grayish  substance  which  increased  in 
consistence  in  proportion  as  it  neared  the  base,  where  it  was 
of  fibrous  hardness  and  appearance,  then  became  fibro-cartila- 
ginous,  and  at  the  base,  where  it  was  adherent  to  the  bony 
outgrowth  from  the  coccyx,  it  was  almost  cartilaginous.  The 
interior  of  the  tumor  was  perforated  with  spaces  inclosing  a 
liquid  matter  resembling  pus.     Cure. 

Case. — Man,  aged  twenty-four  years.  Fibrous  cyst,  size  of 
a  pigeon's  egg,  filled  with  liquid  contents.     Cure. 

Molliere  also  reports  one  case  of  his  own,  in  a  young  girl  in 
whom  the  tumor,  the  size  of  a  small  almond,  was  covered  by 
healthy  skin. 

Walzberg1  also  reports  an  interesting  case  of  operation.  The 
patient  was  a  woman,  aged  twenty-six  years,  from  whom  a  con- 
genital tumor  the  size  of  the  two  fists  was  cut.  A  prolongation 
was  found  extending  so  far  into  the  pelvis  that  it  could  not  be 
followed  to  the  bottom.  The  patient  recovered  from  the  opera- 
tion with  a  deep  pelvic  fistula  remaining. 

From  these  cases,  the  general  characters  of  these  tumors 
may  be  deduced.  They  are  generally  soft,  pasty,  indolent, 
covered  by  healthy  skin  to  which  they  are  not  adherent,  and 
firmly  attached  to  the  sacrum  or  coccyx.  They  occur  most 
frequently  in  adults,  and  seldom  attain  any  size  larger  than 
that  of  a  hen's  egg.  They  grow  slowly  for  a  longer  or  shorter 
time,  until  an  inflammatory  action  is  excited,  when  acute 
symptoms  supervene,  and  they  demand  attention.  They  may 
contain  sebaceous  matter,  hair,  or  teeth,  and  may  be  located 
even  within  the  rectum,  which  is  very  rare,  or  in  the  ano- 
coccygeal region,  which  is  more  common. 

While  speaking  of  tumors  containing  hair,  etc.,  it  may  be 
well  to  refer  to  an  affection  which  Dr.  Hodges,2  of  Boston,  has 
described  under  the  name  of  "pilo-nidal  sinus  "  (pilus,  a  hair  ; 
nidus,  a  nest),  and  which  has  for  some  time  been  known  in 
French  literature  by  the  name  of  the  posterior  umbilicus.  The 
affection  is  simply  a  ball  of  hair  and  dirt  in  a  sinus  between  the 
anus  and  the  tip  of  the  coccyx.  The  sinus  is  a  deep,  sym- 
metrical, somewhat  conical  dimple  of  congenital  origin,  repre- 
senting an  imperfect  union  of  the  lateral  halves  of  the  body, 

1  Deutsch  Z'tsch.  f.  Chir.,  t.  x  ,  Nos.  5  and  6,  November,  1878. 

2  Boston  Med.  and  Surg.  Journal,  November  18,  1880. 


230  DISEASES    OF   THE   RECTUM    AND    ANUS. 

involving  the  integument  alone,  in  which,  as  life  advances, 
short  hairs  and  other  particles  accumulate.  These,  by  their 
irritation,  cause  a  purulent  discharge  from  the  fistulous  open- 
ing of  the  cavity,  and  when  the  case  comes  under  the  observa- 
tion of  the  surgeon,  it  is  usually  mistaken  for  fistula-in-ano. 
The  hair  being  removed,  the  sinus  closes  by  granulation. 

This  affection  is  never  found  in  children,  never  in  men  who  do 
not  have  a  large  amount  of  hair  about  the  nates,  and  so  rarely 
in  women  that  the  records  of  the  Massachusetts  General  Hos- 
pital included  but  a  single  instance,  and  in  this  patient  there 
was,  for  a  female,  an  unusual  growth  of  hair.  For  the  develop- 
ment of  the  affection  there  are  necessary  a  congenital  coccygeal 
dimple,  an  abundant  pilous  growth  (hence  adult  age,  and  al- 
most of  necessity  the  male  sex),  and  insufficient  attention  to 
cleanliness.  The  affection  is,  therefore,  met  with  in  persons  of' 
the  lower  class,  and  in  hospital  rather  than  private  practice. 

Hydatids. — The  number  of  hydatid  cysts  of  the  pelvis  which 
have  been  reported  is  by  no  means  inconsiderable.  F.  Villard ' 
has  collected  thirteen  of  them  in  women,  and  the  standard 
surgical  writers  mention  their  occasional  occurrence.  Bryant 
mentions  removing  a  "  basinful  "  of  secondary  cysts  from  one 
in  this  position.  These  swellings  are  to  be  recognized  by  their 
tense,  globular,  and  elastic  feel,  and  by  the  fact  of  their  causing 
no  symptoms  except  those  due  to  pressure,  except  in  cases  of 
suppuration  after  the  death  of  the  entozoon.  The  cyst  has 
laminated  walls  lined  with  a  granular  layer,  and  is  usually  sur- 
rounded by  a  connective  tissue  capsule  formed  from  the  part 
in  which  it  is  imbedded.  It  may  be  of  any  size,  and  contains  a 
clear,  watery,  albuminous  fluid,  in  which  may  be  found  parts 
of  the  entozoon. 

Foetal  Inclusions. — In  these  congenital  cysts,  any  foetal 
structure  may  be  found.  They  are  not  so  rare  but  that  several 
very  complete  studies  have  been  made  of  them.  Molka  gives 
numerous  examples ;  Verneuil "  has  collected  ten  cases ;  and 
Paul4  has  written  exhaustively  on  the  subject,  his  article  being 
founded  on  a  study  of  twenty-eight  cases.     That  variety  which 

1  Considerations  cliniques  sur  les  Kystes  hydatiques  du  petit  bassin  chez  la  femme. 
Annales  de  Gynecologie,  1878,  p.  101. 

•  Surgery,  p.  152,  American  edition. 

*  Arch.  Gen.  de  Med.,  1855. 

4  Etude  pour  servir  a  l'histoire  des  monstrositcs  parasitaires  de  l'inclusion  foetal 
situe  dans  la  region  Bacro-perineale.     Arch.  Gen.  de  Mul.,  t.  xx.,  1862. 


NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS. 


237 


is  located  in  the  sacro-perineal  region  is  the  most  frequent  of 
all.  (Fig.  75.)  The  sac  is  composed  of  three  layers,  cutaneous, 
fibrous,  and  serous.  The  skin  is  thinned  from  distention,  is 
violet  or  bluish  in  color  from  congestion,  and  an  inflammation 
or  a  spontaneous  rupture  may  cause  perforation  of  the  sac  and 
the  escape  of  the  fluid  contents.  The  fibrous  layer  may  be 
more  or  less  resistant.  It  is  sometimes  composed  of  a  simple 
hypertrophy  of  connective  tissue  ;  at  others  it  is  aponeurotic  in 
character.  When  the  sac  communicates  with  the  spinal  canal, 
this  fibrous  layer  is  a  direct  extension  of  the  dura  mater  of  the 
cord.     The  serous  layer  is  smooth  and  covered  by  pavement 


Fig.  75. — Congenital  Tumor  of  Ano-perineal  Region. 

epithelium,  and  to  one  side  of  it  the  included  foetus  will  be 
found  attached.  This  may  also  be  a  continuation  of  the  arach- 
noid of  the  cord. 

These  cysts  contain  a  serous  fluid  and  foetal  contents  in  the 
form  of  an  irregular  mass,  hard  and  soft  in  spots.  Any  and 
every  part  of  a  foetus  may  be  discovered  in  this  mass.  The 
tumor  is  ovoidal  in  shape,  resembling  an  egg  when  small,  or  the 
scrotum  when  larger.  The  size  is  generally  equal  to  that  of  the 
head  of  the  foetus  which  bears  it,  but  sometimes  equals  that  of 
the  head  at  term,  and  may  be  larger.  The  tumor  may  be  biloc- 
ular  ;  its  contents  generally  give  fluctuation  and  are  irreducible 
except  where  there  is  a  communication  with  the  spinal  canal. 
There  is  no  pain  unless  inflammation  has  supervened.  The 
diagnosis  is  generally  made  by  discovering  a  hard  mass  of  foetal 


238  DISEASES    OF   THE    RECTUM    AND    ANUS. 

elements  in  the  midst  of  a  serous  cyst.  When  the  cyst  com- 
municates with  the  spinal  canal,  the  differential  diagnosis  be- 
tween it  and  a  spina  bifida  may  be  impossible. 

Such  a  cyst  may  cause  death  by  obstructing  labor,  or  by  the 
development  of  a  gangrenous  inflammation  after  birth.  As  a 
rule,  operations  for  their  removal  have  not  resulted  successfully 
when  undertaken  during  the  first  three  years  of  life.  One  oper- 
ation practised  at  a  later  date  has,  however,  been  crowned  with 
success. 

Spina  Bifida. — Concerning  this  variety  of  cyst  little  need  be 
said  except  as  regards  its  diagnosis.  It  should  be  borne  in 
mind  that  a  tumor  due  to  a  deficiency  of  the  spinal  bones  may 
be  entirely  within  the  pelvis,  in  which  case  it  would  present 
great  difficulties  in  diagnosis.     Such  a  case  is  the  following.1 

Case. — Woman,  aged  thirty-six  ;  single.  The  patient  stated 
that  ten  years  before  she  detected  a  swelling  as  large  as  a  goose 
egg  in  the  right  iliac  region,  her  attention  having  been  called 
to  it  by  shooting  pains  through  the  abdomen  starting  from 
this  point.  The  size  of  the  tumor  increased  slowly,  had  once 
caused  retention  of  urine,  and  now  caused  oedema  of  the  right 
leg.    The  patient  was  cachectic  and  emaciated. 

The  abdomen  was  uniformly  enlarged  and  tympanitic.  On 
making  a  vaginal  examination,  the  cervix  uteri  could  be  scarcely 
reached,  situated  as  it  was  above  the  pubes,  while  a  mass  was 
felt  behind  in  the  cul-de-sac,  extending  to  the  right,  apparently 
an  ovarian  cyst.  But  from  a  digital  examination  in  the  rectum 
it  was  evident  that  the  rectum  was  pushed  forward  by  a  large, 
soft,  fluctuating  tumor  behind  it,  which  filled  up  the  hollow  of 
the  sacrum  to  within  a  short  distance  of  the  anus. 

The  patient  was  placed  under  ether,  and  a  fine  trocar  was 
introduced  into  the  sac,  about  three  inches  beyond  the  anus,  by 
which  an  ounce  or  more  of  its  contents  were  aspirated  by  Dieu- 
lafoy's  pump.  This  fluid  was  serous  in  character,  perfectly 
clear  and  limpid,  resembling  hysterical  urine.  It  contained  no 
albumen,  and  the  microscope  revealed  nothing  more  than  a  few 
oil-globules,  which  had,  beyond  question,  been  attached  to  the 
instrument  before  its  introduction. 

Autopsy,  nine  and  a  half  hours  after  death.  On  opening  the 
abdomen,  the  colon  was  so  much  distended  as  to  fill  the  whole 

1  Emmet :  Prin.  and  Prac.  of  Gynecology,  first  edition,  p.  773. 


NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS.       239 

cavity,  and  reached  to  a  level  of  the  fourth  rib,  being  filled  with 
11a tus  and  f feces.  ...  A  cyst  which  contained  some  three 
quarts  of  fluid  was  found  behind  and  to  the  right  of  the  rectum, 
filling  completely  the  cavity  of  the  pelvis,  and  extending  up  to  a 
line  with  the  second  lumbar  vertebra.  .  .  .  The  rectum  was 
greatly  constricted  in  its  upper  portion.  ...  In  attempt- 
ing to  discover  the  attachments  of  the  cyst  in  the  hollow  of  the 
sacrum  it  was  ruptured.  The  sacrum  was  removed  and  a  spina 
bifida  found,  the  three  lower  bones  of  the  sacrum  being  defi- 
cient on  the  right  side.  A  funnel-shaped  opening  communi- 
cated directly  with  the  spinal  canal,  from  which  projected  por- 
tions of  the  cauda  equina  an  inch  or  more  in  length.  .  .  . 
Although  the  posterior  portion  of  the  bones  were  wanting,  no 
external  bulging  of  the  sac  could  take  place  posteriorly  in  con- 
sequence of  the  dense  ligamentous  structures  bridging  it  over. 

The  diagnosis  of  spina  bifida  can  generally  be  made  by  the 
reducibility  of  the  tumor,  the  signs  of  pressure  on  the  brain  and 
spinal  cord  which  are  produced  by  pressure  on  the  tumor,  the 
fluctuation  at  the  fontanelles,  and  the  chemical  character  of  the 
fluid  which  may  be  withdrawn  for  the  purpose  of  diagnosis. 
The  fluid  of  a  spina  bifida  contains  both  sugar  and  urea,  as  does 
that  of  the  cerebro -spinal  canal,  and  though  both  these  sub- 
stances may  be  found  in  cysts  entirely  independent  of  the  cere- 
brospinal canal,  they  will  always  be  found  in  spina  bifida. 

There  still  remains  a  class  of  congenital  cysts  which  are 
neither  connected  with  the  spinal  canal  (spina  bifida)  nor  para- 
sitical (containing  foetal  remains).  These  are  often  of  large  size 
at  the  time  of  birth,  and  may  consist  of  a  single  cyst  or  be  mul- 
tilocnlar.  They  are  generally  attached  by  a  pedicle  near  the 
tip  of  the  coccyx,  though  the  cyst  or  cysts  may  have  prolonga- 
tions in  the  perineum  or  the  ischio-rectal  fossae.  The  cyst- wall 
in  these  cases  is  fibrous,  and  when  many  cysts  are  present  it 
sends  prolongations  between  them.  The  integument  covering 
it  is  thin  and  generally  marked  by  large  veins.  The  cyst  is 
filled  with  a  yellowish,  tenacious,  gelatinous  fluid,  transparent 
to  light  as  is  a  hydrocele.  It  will  be  seen  at  once  that  the  great 
difficulty  in  diagnosis  lies  between  this  form  of  cyst  and  a  spina 
bifida,  and  though  the  diagnosis  may  not  always  be  possible,  it 
will  generally  turn  upon  the  presence  or  absence  of  the  signs  of 
communication  with  the  spinal  canal  when  pressure  is  made 
upon  the  tumor. 


240  DISEASES    OF    THE    RECTUM    AND    ANUS. 

The  treatment  of  these  growths  is  by  extirpation.  Injec- 
tions of  iodine,  etc.,  have  in  them  the  element  of  danger  from 
prolonged  and  extensive  suppuration.  When  extirpation  is  at- 
tempted it  should  be  complete ;  and  where  the  cyst  is  multi- 
locular  it  should  be  followed  into  the  perineum  and  ischio- 
rectal fossae  if  necessary,  in  order  that  no  parts  of  it  may  remain 
to  undergo  subsequent  development.1  These  cystic  formations, 
unless  of  sufficient  size  to  cause  death  during  labor,  are  not  in- 
compatible with  life. 

1  Buneau  :  Bull,  de  la  Soc.  Med.  de  la  Suisse  romande  (Molli^re). 


CHAPTER  X. 

NON-MALIGNANT  ULCERATION. 

Varieties. — Simple  Ulcers. — Generally  due  to  Traumatism. — Various  Forms  of  Injury 
to  which  Rectum  is  Subject. — Sodomy. — Injury  of  Rectum  in  Labor. — Ulcers 
due  to  Surgical  Interference. — Fissure  or  Irritable  Ulcer. — Nothing  Distinctive  in 
the  Ulcerative  Process. — Characteristics  of  Irritable  Ulcer. — Theories  concerning 
this  Form  of  Ulcer. — Description. — Herpes. — Tubercular  Ulceration. — Distinc- 
tion between  True  Tubercular  Ulcer  and  a  Simple  Ulcer  in  a  Tuberculous  Person. 
— Description  of  Each. — Scrofulous  Ulceration. — Esthiomene. — Rodent  Ulcer. — 
Dysentery. — A  Cause  of  Stricture. — Venereal  Ulceration. — Gonorrhoea — Chan- 
croids. —  Chancroidal  Stricture.  —  Discussion.  —  True  Chancre.  —  Secondary  and 
Tertiary  Syphilitic  Ulcerations.  —  Diagnosis  of  Syphilitic  Ulcers. — Ano-rectal 
Syphiloma  as  a  Cause  of  Ulceration. — Ulceration  Secondary  to  Stricture. — Gan- 
grene.— Symptoms  of  Ulceration. — Gravity  of  the  Disease. — Diagnosis. — Treat- 
ment.— General  and  Local  Measures. — Treatment  of  Fissure. — Fissure  Compli- 
cated with  Polypus.  — Treatment  by  Rest,  Fluid  Diet,  and  Incision  of  the 
Sphincter. — Local  Applications. 

The  many  different  varieties  of  non- malignant  ulcers  which  are 
met  with  at  the  anus  and  within  the  rectum  may  best  be  clas- 
sified, from  the  stand -point  of  etiology,  into  the  following 
groups :  1.  Simple.  2.  Tubercular.  3.  Scrofulous.  4.  Dysen- 
teric. 5.  Venereal.  6.  Those  due  to  stricture.  7.  Those  due 
to  gangrene  around  the  rectum. 

Simple  Ulcers. — These  are  almost  always  of  traumatic  origin, 
and  the  most  frequent  traumatism  to  which  the  rectum  is  sub- 
ject is,  perhaps,  that  arising  from  the  presence  and  passage  of 
hardened  faeces.  From  this  cause  alone,  or  from  this  combined 
with  their  extrusion  from  the  anus,  the  surface  of  projecting 
hemorrhoidal  tumors  may  become  ulcerated  for  a  considerable 
extent ;  and,  by  this  means,  a  fissure  is  often  produced  within 
the  grasp  of  the  sphincter.  The  latter  I  have  known  to  happen 
on  the  first  evacuation  of  the  bowels  after  an  operation  for  haem- 
orrhoids (the  bowels  having  been  confined  by  medicine  for  several 
da}^s),  rendering  necessary  the  usual  operation  for  its  cure  at  a 
subsequent  time.  Another  frequent  cause  of  direct  injury  is  the 
presence  of  foreign  bodies,  either  fish-bones,  date-stones,  etc., 

16 


242  DISEASES    OF   THE    KECTUM    AND    ANUS. 

which  have  been  swallowed,  or  larger  substances  which  have 
been  intentionally  introduced  per  anum.  The  presence  of  such 
substances  may  excite  extensive  ulceration  which  will  lead  to 
subsequent  stricture. 

An  infrequent  cause  of  direct  violence  to  the  rectum,  and  of 
subsequent  ulceration  due  to  the  direct  injury,  and  independent 
of  any  venereal  disease,  is  sodomy,  either  attempted  or  accom- 
plished. Burgeon '  describes  the  rectum  of  an  idiot,  who  for  a 
considerable  time  had  practised  this  vice,  as  much  dilated  and 
infundibuliform  in  shape,  the  mucous  membrane  as  blackish, 
swollen,  and  ulcerated  in  spots,  and  the  submucous  and  mus- 
cular layers  as  hypertrophied  to  four  or  five  lines  in  thickness. 
It  is  doubtful  whether  passive  pederasty  should  be  included 
among  the  causes  of  stricture,  as  the  injury  done  does  not  gen- 
erally reach  to  this  extent,  and,  indeed,  the  anus  is  not  often 
dilated  to  any  such  extent  as  in  this  case.  Ligg 2  describes  a 
deaf-mute,  thirty-live  or  forty  years  of  age,  the  victim  of  this 
habit,  whose  anus  offered  no  trace  of  traumatism,  and  was  well 
closed,  being  marked  only  by  the  absence  of  the  radiating  folds. 
The  mucous  membrane  of  the  rectum  also  was  normal.  I  have 
also  had  a  patient  come  to  me  for  supposed  rectal  trouble  in 
whom  the  rectum  and  anus  were  both  perfectly  normal,  who 
voluntarily  confessed  to  having  practised  this  vice  for  years. 
The  habit  is  one  to  be  looked  for  in  negroes,  and  in  sailors  when 
upon  a  long  voyage.  This  absence  of  the  radiating  folds,  to- 
gether with  the  presence  of  spermatozoa  in  the  rectum  or  in  the 
mucous  discharge  from  it,  are  given  as  the  best  medico-legal 
proofs  of  the  vice.3 

An  injury  to  which  women  alone  are  subject,  and  which  is 
believed  by  many  to  go  far  toward  accounting  for  the  greater 
frequency  of  ulceration  and  stricture  in  them  than  in  men,  is 
bruising  of  the  rectal  wall  between  the  head  of  the  foetus  and 
the  sacrum  in  parturition.  Most  of  the  standard  authors  men- 
tion such  cases. 

An  ulcer  of  the  rectum  is  a  not  infrequent  result  of  surgical 
interference  with  diseases  of  this  part.  -Although  in  certain 
subjects  a  wound  made  by  the  surgeon  may  refuse  to  heal  under 

1  Bull,  de  la  Soc.  Anat.,  ia30,  p.  80. 

sCorr.  Bl.  f.  echweiz.  Aerzte,  No.  3,  p.  71,  February  1,  1879. 

3  See  Lecons  sur  les  Deformations  Vulvaires  et  anales  Produities  par  la  Masturba- 
tion, etc.     Martineau,  Paris,  1884. 


NON-MALIGNANT    ULCERATION.  .  243 

the  best  of  treatment,  ulceration  from  this  cause  will  generally 
be  found  to  be  due  to  careless  or  ignorant  manipulation,  rather 
than  to  the  unfortunate  constitutional  state  of  the  patient. 
Two  cases  occur  to  me  now  :  one  of  a  large  ulcer,  with  hard  and 
elevated  edges,  looking  much  like  a  true  chancre,  which  re- 
sulted from  the  persistent  application  of  caustics  to  a  simple 
fissure  ;  and  another,  of  three  separate  ulcers  which  marked  the 
former  site  of  three  internal  haemorrhoids  which  had  been  re- 
moved by  ligatures.  The  patient  suffered  only  slight  discom- 
fort from  the  operation,  and  was  allowed  to  go  to  his  business 
on  the  following  day — a  thing  which  may  sometimes  be  done 
with  apparent  impunity,  but  which  should  never  be  counte- 
nanced by  the  operator. 

The  application  of  nitric  acid  to  prolapse  is  said  to  have 
been  followed  by  disastrous  ulceration  and  stricture,  but  such 
need  not  be  the  case,  nor  is  any  such  use  of  the  acid  necessary 
to  effect  a  cure  in  any  case  where  its  use  is  indicated  at  all. 
Prolapse  is  not,  however,  a  rare  cause  of  stricture,  due  to  the 
strangulation  and  sloughing  of  the  prolapsed  portion,  and  to 
the  subsequent  cicatrization. 

Irritable  Ulcer,  or  Fissure. — An  injury  due  to  any  of  the 
causes  already  mentioned  may,  in  certain  persons,  and  when 
located  at  the  verge  of  the  anus,  assume  the  characteristics  of 
an  affection  which  has  been  elevated  into  a  separate  class,  and 
is  known  as  fissure,  or  irritable  ulcer.  The  irritable  ulcer  dif- 
fers in  no  respect  from  other  simple  ulcers  in  the  same  locality, 
except  in  the  fact  of  its  irritability.  There  is  nothing  peculiar 
in  the  ulcer  itself.  It  may  be  due  to  a  slight  rent  in  the  mucous 
membrane  from  hard  faeces ;  to  a  congenital  narrowness  of  the 
anal  orifice  and  a  naturally  over-powerful  sphincter  ;''  to  the  irri- 
tation of  a  leucorrhoeal  discharge  in  women  ;  to  an  herpetic  ves- 
icle, or  to  the  venereal  sore  which  it  so  strongly  resembles — the 
soft  chancre.  Any  sore  which  is  fairly  in  the  grasp  of  the  ex- 
ternal sphincter  is  apt  to  become  an  irritable  or  painful  one  ; 
and  a  fissure  may  be  painless  at  one  time  and  painful  at  an- 
other in  the  same  person,  or  painless  in  one  person  and  painful 
in  another. 

For  this  reason  Gosselin2  has  divided  these  ulcers  into  two 
distinct  varieties,  the  tolerant  and  intolerant — a  classification 

1  Molliere  :  Sarremone,  These  de  Strasbourg,  1861,  No.  555,  p.  134. 
'  Diet,  de  Mud.  et  de  Chirurg.  Prat ,  art.  Anus. 


244  DISEASES    OF   THE    RECTUM    AND    ANUS. 

which  Molliere '  still  further  improves  by  suggesting  the  words 
tolerable  and  intolerable.  An  ulcer  associated  with  contracture, 
spasm,  irritability,  and  sometimes  with  actual  hypertrophy  of 
the  sphincter  is  what  is  known  as  an  irritable  one  ;  and  without 
this  condition  of  the  muscle  it  will  not  properly  come  under 
this  classification. 

This  contracture  of  the  muscle  may  be  temporary  or  per- 
manent, and  is  due  to  the  irritation  of  the  sensitive  nerve  fila- 
ments on  the  surface  of  the  ulcer  by  the  passage  of  faeces,  and 
to  the  reflex  action  excited  thereby ;  and  to  many  slighter 
causes,  such  as  laughing,  coughing,  sneezing,  or  position.  It 
may  even  come  on  spontaneously  in  persons  of  a  highly  nervous 
organization,  or  with  such  slight  provocation  as  to  appear  to  be 
spontaneous. 

There  are  two  well-known  theories  regarding  the  causation 
of  this  little  sore.  According  to  Boyer,a  the  foundation  of  the 
trouble  is  a  spasm  of  the  sphincter  muscle,  and  the  fissure  is 
merely  a  secondary  lesion  due  to  the  passage  of  faeces  through 
the  spasmodically  contracted  anus.  Trousseau,3  on  the  other 
hand,  reverses  the  relation,  and  very  properly,  holding  that  the 
fissure  exists  first,  and  that  the  spasm  of  the  sphincter  and  the 
resulting  pain  are  reflex,  being  specially  apt  to  occur  in  persons 
of  neuralgic  tendency,  and  being  in  many  cases  merely  the  local 
manifestations  of  a  general  nervous  state. 

Although  these  ulcers  are  generally  stated  to  be  due  to  an 
actual  laceration  of  the  mucous  membrane,  or  to  its  abrasion 
from  some  irritation,  they  not  unfrequently  originate  within  the 
sinuses  of  Morgagni,  and  a  true  fissure  may  be  entirely  con- 
cealed from  view  within  one  of  these  pouches,  as  in  the  follow- 
ing instructive  case  reported  by  Dr.  Vance,4  which  for  brevity  I 
will  slightly  condense. 

Case.  Inflammation  of  one  of  the  Sinuses  of  Morgagni. — 
A  lady,  aged  eighteen,  had  suffered  for  more  than  a  year  from 
all  the  symptoms  of  fissure,  had  been  frequently  examined  to 
no  purpose,  and  was  reduced  to  a  very  miserable  state.  On  ex- 
amination the  integumentary  folds  were  congested,  thickened, 
and  oedematous,  doubtless  as  a  result  of  constant  scratching, 
but  there  was  no  trace  of  anything  like  a  fissure.     The  lining 

1  Op.  cit,  p.  149.  5  Traitii  des  Maladies  Chirurg.,  t.  x.,  p.  105. 

3  Clin.  M'd.,  t.  iii.,  art.  Fissure. 

'  Medical  and  Surgical  Reporter,  August  14,  1880. 


NON-MALIGNANT    ULCERATION.  245 

membrane  was  searched  with  the  utmost  care,  but  no  lesion  of 
any  sort  was  revealed  except  slight  hypertrophy  of  the  sphinc- 
ter. A  second  painstaking  review  of  every  part  of  the  rectum 
gave  the  same  result,  and  the  author  was  about  to  abandon  the 
hope  of  finding  any  local  lesion,  when  as  a  matter  of  form— for 
there  was  no  evidence  of  disease  about  them — he  determined  to 
pass  a  probe  into  each  of  the  pouches.  The  prObe  could  not  be 
forced  into  the  first  one,  and  with  the  second  he  fared  no  better, 
but  with  the  third,  after  an  ineffectual  attempt,  the  probe  passed 
into  the  saccnlus. 

No  sooner  had  the  probe  entered,  however,  than  the  patient 
screamed  with  pain,  and  there  was  a  spasmodic  retraction  of 
the  levator  ani  and  sphincter  muscles  and  the  part  was  forcibly 
withdrawn  from  view.  The  site  of  the  sacculus  felt  as  if  a  buck- 
shot had  been  imbedded  in  the  tissues,  so  hard  and  swollen  was 
the  part.  A  small  probe-pointed  tenotome  was  carefully  passed 
along  the  canal,  and  as  soon  as  the  sensitive  point  was  touched, 
the  handle  was  brought  down  and  the  edge  of  the  knife  made 
to  sever  the  inner  wall  of  the  sacculus  and  expose  the  diseased 
point.  This  done  the  cause  of  the  suffering  was  revealed.  On 
the  left  side  of  the  anus,  and  at  a  point  where  there  had  been 
no  unusual  sensibility,  an  indurated  ulcer  had  formed  within 
one  of  the  little  pouches.  When  the  sacculus  was  opened  and 
the  ulcer  exposed,  it  seemed  very  much  like  an  ordinary  fissure 
of  the  anus,  but  before  cutting  it  open  there  was  no  evidence 
whatever,  save  the  symptoms  the  patient  complained  of,  to  in- 
dicate the  existence  of  such  a  lesion. 

These  ulcers  are  generally  situated  at  the  posterior  commis- 
sure, but  may  be  found  anywhere  on  the  anal  circumference. 
They  are  generally  single,  but  there  may  be  two  or  three,  more 
especially  when  of  venereal  origin.  They  are  more  common  in 
women  than  in  men,  because  constipation  is  more  common  in  the 
former  and  because  the  skin  is  finer.  •  They  are  confined  to  no 
age  and  are  by  no  means  relatively  rare  in  infants.  They  are 
generally  oval  in  shape  with  their  long  axis  vertical,  and  involve 
both  skin  and  mucous  membrane,  being  situated  just  at  the  junc- 
tion of  the  two.  In  some  cases  they  have  the  appearance  of  a 
simple  erosion,  in  others  of  an  old  ulcer  with  grayish  base  and  in- 
durated edges  which  has  involved  the  whole  thickness  of  the  mu- 
cous membrane  and  extended  fairly  down  to  the  muscle  beneath. 
In  the  majority  of  cases  they  are  not  attended  by  suppuration  or 


246  DISEASES    OF    THE    RECTUM    AND    ANUS. 

the  discharge  of  pus.  They  may  exist  for  years  without  gaining 
in  surface  or  depth.  Allingham '  has  pointed  out  how  commonly 
they  are  attended  by  small  polypi  situated  at  their  upper  end 
or  on  the  opposite  side  of  the  rectum  ;  and  they  will  often  be 
found  in  conjunction  with  haemorrhoids  and  condylomatous 
tags,  the  dragging  upon  which  in  the  act  of  defecation  has 
seemed  to  me  in  some  cases  to  account  mechanically  for  a  slight 
tearing  of  the  mucous  membrane. 

An  eruption  of  herpes  around  the  anus,  similar  to  what  is 
seen  on  the  lips,  may  result  after  rupture  of  the  primary  vesi- 
cles in  numerous  small  superficial  ulcers  of  a  reddish  color  and 
secreting  a  little  pus.  These  may  coalesce  at  their  edges  and 
form  a  serpiginous  sore.  They  are  apt  to  be  accompanied  by 
similar  eruptions  on  other  parts  of  the  body,  and  must  be  care- 
fully distinguished  both  from  mucous  patches  and  soft  chan- 
cres. The  ulcerations  which  result  from  acute  and  chronic 
eczema  and  from  pruritus  present  no  special  characteristics. 
They  are  generally  due  to  the  injury  inflicted  by  the  nails  of 
the  sufferer. 

From  what  has  been  said  of  the  etiology  of  these  simple 
ulcers  it  is  plain  that  they  must  present  many  variations  in  ap- 
pearance ;  yet  the  diagnosis  of  each  from  the  other,  and  of  the 
whole  class  from  those  which  are  to  follow,  will  not  generally 
be  found  difficult  if  proper  attention  is  given  to  the  history,  the 
appearance  of  the  lesion,  and  its  course.  The  disease  is  gener- 
ally of  a  healthy  type,  and  tends  to  self-limitation  and  sponta- 
neous cure  rather  than  to  increase.  The  ulcerative  action  is 
generally  superficial,  and  tends  to  extend  on  the  surface  rather 
than  in  depth.  It  is  generally  surrounded  by  the  signs  of  re- 
parative action,  and  with  proper  care  will  undergo  cicatrization, 
which,  when  extensive,  will  result  in  stricture. 

Tubercular  Ulcers. — There  are  two  varieties  of  ulceration 
met  with  in  persons  of  the  tubercular  diathesis  ;  one  due  to  the 
actual  deposit  and  softening  of  tubercle,  the  other  a  simple 
ulceration  containing  no  tubercular  deposit,  but  modified  in  its 
course  by  the  patient's  general  condition  of  malnutrition.  The 
former  may  properly  be  called  tubercular  ulceration,  and  the 
latter  is  better  known  as  the  ulceration  of  the  tuberculous.  The 
former  is  very  rare.     It  may  occur  in  the  rectal  pouch  or  indeed 

1  Op.  cit.,  p.  19?. 


NON-MALIGNANT    ULCERATION.  247 

anywhere  along  the  course  of  the  alimentary  canal,  but  its 
favorite  site  is  at  the  verge  of  the  anus,  where  it  may  exist 
before  any  general  manifestation  of  tuberculosis. 

The  characters  by  which  such  an  ulcer  may  be  recognized 
are  its  pale -red  surface  covered  with  a  small  quantity  of  serum, 
but  devoid  of  healthy  pus  and  appearing  as  if  varnished  ;  the 
absence  of  all  surrounding  inflammation  and  of  the  granulations 
which  exist  in  a  healthy  sore  ;  its  tendency  to  spread  in  depth 
rather  than  on  the  surface  ;  the  absence  of  any  marked  pain  ; 
the  regular  outline  ending  abruptly  in  healthy  skin ;  and  above 
all  its  chronicity  and  the  utter  failure  of  all  remedies  to  affect 
its  steady  course.  The  diagnosis  may  be  confirmed  by  the 
microscope '  and  the  disease  is  analogous  to  tuberculosis  of  the 
larynx,  which,  however,  has  been  studied  much  more  thoroughly. 
Fig.  76. 

Whether  such  an  ulcer  is  ever  a  cause  of  stricture  is  doubt- 
ful, it  being  doubtful  whether  a  truly  tubercular  ulceration  in 
this  place  ever  heals,  or,  in  other  words,  results  in  the  forma- 
tion of  contractile  tissue.  It  is  exceedingly  difficult  to  induce 
them  to  take  on  a  healthy  reparative  action  ;  and  if  cicatrization 
begins,  the  process  is  generally  incomplete,  and  the  cicatrix  easily 
breaks  down.  Sands,2  however,  relates  a  case  of  stricture  in  a 
boy  aged  eighteen,  due  to  tubercular  deposit,  both  in  the  rectum 
and  peritoneum,  for  which  he  performed  colotomy,  the  deposit 
being  on  the  anterior  wall  at  the  level  of  the  pubic  symphysis, 
and  the  rectum  being  so  nearly  occluded  as  not  to  allow  of  the 
passage  either  of  an  instrument  or  an  injection.  On  autopsy,  a 
portion  of  the  small  intestine  seven  feet  long,  was  also  found  to 
be  so  narrowed  as  to  admit  of  the  passage  only  of  a  full-sized 
bougie,  but  the  narrowing  in  both  cases  seems  to  have  been  due 


1  In  the  excellent  monograph  of  Pean  et  Malassez,  Etude  clinique  sur  les  Ulcera- 
tions anales,  Paris,  1872,  there  may  be  found  the  history  of  a  case  of  this  kind  with 
the  microscopic  report  and  drawing  of  Cornil.  Gosselin  also  gives  a  clinical  lecture 
on  a  similar  case  in  the  Gaz.  Med.  de  Paris,  March  27,  1880,  calling  attention  to  the 
main  points  in  the  diagnosis  and  treatment  ;  and  Allingham  speaks  of  cases  in  which 
the  diagnosis  was  confirmed  by  Paget,  and  remarks  parenthetically  that  the  disease  is 
not  as  rare  as  is  generally  supposed.  Other  literature  on  the  subject  may  be  found 
in  Habershon,  On  the  Diseases  of  the  Abdomen,  p.  302  et  seq.,  London,  1862;  in  Mol- 
liere,  Traite  des  Maladies  du  Rectum  et  de  l'Anus,  Paris,  1877  ;  Spillmann,  De  la 
tuberculization  du  tube  digestif  (These  d'agrigation  en  Medecine,  1878);  and  Lion- 
ville,  Bull.  Soc.  Anat.,  1874. 

5  N.  Y.  Med.  Journ.,  April  and  December,  1865. 


248  DISEASES    OF   THE    RECTUM    AND    ANUS. 

rather  to  the  encroachment  of  the  tubercular  mass  than  to  cica- 
trization and  subsequent  contraction. 

A  tubercular  ulcer  starting  in  the  wall  of  the  rectum  may 
end  in  perforation  and  fistula  (fistula  with  large  internal  open- 
ing), and,  as  a  matter  of  course,  the  usual  operation  in  such  a 
case  would  be  followed  only  by  disappointment.  Such  an  ulcer 
has  also  been  known  to  cause  sudden  death  from  haemorrhage 
in  a  child,  aged  four  years,  the  subject  of  acute  general  tuber- 
culosis.1 


Fig.  76. — Tubercular  Ulceration.    (Esmarch.) 

The  treatment  is,  therefore,  only  palliative,  though  Molliere1 
propounds  the  interesting  question  whether,  if  such  an  nicer 
were  completely  extirpated  or  destroyed,  before  general  symp- 
toms of  tuberculosis  had  shown  themselves,  it  might  not  be 
possible  to  prevent  the  general  manifestation  of  the  disease,  as 
may  be  done  in  cases  of  tubercular  testis.  He  bases  the  ques- 
tion on  a  case  in  which  such  an  ulcer  existed  nearly  four  years 
before  any  other  sign  of  tuberculosis  was  apparent. 

'  Ashby :  Trans.  Manchester  Med.  Soc,  Brit.  Med.  Journ. ,  July  31,  1880. 
'Op.  cit.,  p.  651. 


NON-MALIGNANT    ULCERATION.  249 

The  other  variety  of  so-called  tubercular  ulcer  is  a  simple 
sore  in  a  phthisical  patient,  modified  in  its  course  and  charac- 
teristics by  the  general  condition.  It  may  result  from  any  of 
the  causes  already  mentioned,  and  any  of  the  varieties  already 
described  may,  under  the  proper  conditions,  assume  its  charac- 
teristics. It  may  occur  either  within  the  rectum  or  at  the  anus, 
and  may  vary  in  size  from  a  mere  spot  a  quarter  of  an  inch  in 
diameter  to  a  sore  covering  the  whole  lower  part  of  the  rectum. 
It  may  extend  in  depth  as  well  as  on  the  surface,  may  perforate 
and  cause  abscess  and  fistula,  or  be  attended  by  thickening  of 
the  wall  without  decrease  in  calibre.  It  is  often  accompanied 
by  numerous  polypoid  growths  ;  it  is  generally  painful,  and  the 
discharge  is  purulent.  It  neither  extends  rapidly  nor  heals 
easily,  and  yet  it  is  surrounded  by  a  healthy  reparative  action, 
and,  unlike  the  true  tubercular  sore,  it  may  be  induced  to  heal, 
and  is  one  of  the  causes  of  grave  stricture.  The  process  is 
essentially  a  chronic  one,  and  several  of  the  cases  of  "chronic 
ulceration  of  the  rectum  "  reported  by  Curling  come  properly 
under  this  category.  It  may  easily  be  distinguished  from  true 
tubercle,  but  may  readily  be  confounded  with  some  of  the 
varieties  which  are  to  follow. 

Scrofula. — Allied  to  the  class  of  ulcers  last  named  are  those 
in  which  the  scrofulous  taint  manifests  itself,  as  it  may  do 
either  in  follicular  ulcers  of  the  rectum  and  large  intestine,  in 
lupus  or  esthiomene,  and  in  rodent  ulcer.  The  last  two  affect 
primarily  the  anus  and  perineum. 

Follicular  ulceration  is  due  to  a  chronic  inflammation  and 
fatty  degeneration  of  the  follicles  of  the  rectum.  These  which, 
when  first  affected,  appear  as  small  caseous  nodules,  break  and 
leave  small,  deeply  excavated  ulcers,  which,  being  multiple, 
may  coalesce  and  leave  larger  ones  of  the  chronic  variety,  capa- 
ble of  subsequent  healing  with  the  formation  of  cicatricial 
tissue. 

They  may  perforate  the  bowel  or  form  fistulse  of  the  blind 
internal  variety  when  low  down,  or  cause  peritonitis  when 
higher  up.  They  may  be  only  one  of  many  manifestations  of 
the  scrofulous  tendency  in  the  same  patient,  and  they  fre- 
quently co-exist  with  pulmonary  disease. 

Under  the  title  of  esthiomene  (lupus  exedens  of  the  ano- 
vulvar  region)  a  number  of  phagedenic  ulcerations,  complicated 
with  more  or  less  hypertrophy  of  the  nature  of  elephantiasis. 


*250  DISEASES    OF    THE    RECTUM    AND    ANUS. 

have  probably  been  described  ;  but,  in  spite  of  the  confusion  of 
statement,  this  would  seem  to  be  a  rare  manifestation  of  scrof- 
ula, which  may  precede  any  others  in  its  development.  It 
commonly  starts  from  the  external  organs  of  generation  in  the 
female,  and  invades  the  anus,  rectum,  and  vagina  secondarih\ 
It  is  almost  never  seen  in  men.  Its  favorite  starting-point  is  in 
the  perineum,  and  instead  of  being  superficial,  it  may  be  per- 
forating and  produce  great  loss  of  tissue,  turning  the  rectum 
and  vagina  into  one  cavity.  At  this  stage  other  ulcers  are  apt 
to  appear  in  the  rectum  and  colon,  causing  diarrhoea  and  some- 
times peritonitis  ;  but  whether  these  are  of  the  variety  just  de- 
scribed as  follicular,  or  are  due  to  further  deposits  of  lupus,  has 
not  yet  been  positively  decided. 

The  ulcer  is  irregular  in  outline,  with  a  granular  base  of  a 
violet-red  color,  and  there  is  a  slight  sanious  discharge.  The 
edges  are  but  little  elevated,  and  are  not  undermined,  and  there 
is  more  or  less  hypertrophy  of  the  surrounding  tissue  which,  in 
some  cases,  is  exceedingly  well  marked.  The  ulcer  may  cica- 
trize in  part,  the  cicatrix  being  thin  and  white,  at  the  same  time 
that  the  ulcerative  process  is  extending  in  the  opposite  direc- 
tion. At  a  little  distance  from  the  ulcer  there  is  often  a  path- 
ognomonic appearance  of  slight,  reddish,  hard  nodules  of  tu- 
bercular lupus,  separated  from  the  primary  sore  by  healthy 
skin.  With  this  amount  of  disease  the  constitutional  disturb- 
ance is  often  not  sufficient  to  confine  the  patient  in  the  house. 

The  diagnosis  is  not  generally  difficult,  though  the  disease 
may  be  confounded  with  cancer,  phagedenic  chancroid,  and 
with  elephantiasis  with  secondary  ulceration.  It  is  best  dis- 
tinguished from  cancer  by  the  cicatricial  bands  which  it  leaves 
behind  in  its  ineffectual  attempts  at  healing,  and  from  chan- 
croid by  the  surrounding  tubercles  which  in  lupus  develop  in 
the  thickness  of  the  derma,  and  ulcerate  secondarily  ;  while  the 
ulcers  which  sometimes  surround  a  chancroid  are  ulcerous  from 
the  first,  being  due  to  secondary  inoculation.  Van  Buren  ad- 
vances the  theory  that  most  of  these  ulcerations  are  due  to  the 
grafting  of  the  syphilitic  poison  upon  the  scrofulous  diathesis 
in  women  of  improper  lives.  The  duration  of  the  disease  is  in- 
definite, and  it  seldom  leads  to  fatal  results.  It  is  best  treated 
by  destructive  cauterization  and  raclage.1 

1  See  also  Huguier.  Mm.  Acad,  de  Med. .  1849;  Harday,  Scrofule  et  Scrofulides, 
p.  80  ;  and  Pcan  et  Malasscz  op.  cit. 


NON-MALIGNAXT    ULCERATION.  251 

Rodent  Ulcer  is  very  closely  allied  to  epithelioma,  and  may;, 
in  fact,  be  considered  one  of  its  varieties  ;  but  it  is  distin- 
guished from  it  clinically  by  the  fact  that  it  does  not  infiltrate 
surrounding  tissue,  does  not  involve  the  lymphatics,  and  does 
not  become  generalized.  It  is  the  same  disease  met  with  upon 
the  face,  and  is  exceedingly  rare  at  the  anus,  being  seen  only 
twice  in  four  thousand  consecutive  cases  at  St.  Mark's  Hospital. 

According  to  the  classical  description  of  Allingham,  it  is 
found  by  preference  at  the  verge  of  the  anus,  and  extending 
from  this  point  upward  into  the  rectum.  It  is  irregular  in 
shape,  and  its  edges  end  abruptly  in  healthy  tissue.  Its  sur- 
face is  red  and  dry  ;  it  destroys  superficially,  attacking  mucous 
membrane  rather  than  skin,  and  undergoes  rapid  but  only 
partial  cicatrization  under  proper  local  and  constitutional  treat- 
ment. It  never  entirely  heals,  and  is  not  to  be  included  among 
the  causes  of  stricture.  It  is  at  first  generally  mistaken  for  a 
late  syphilitic  manifestation,  but  is  distinguishable  from  it  by 
the  powerlessness  of  all  treatment  to  prevent  its  steady  prog- 
ress. It  is  one  of  the  most  painful  of  all  the  ulcerative  affec- 
tions of  this  part,  and  ends  fatally,  unless  some  other  disease 
cuts  short  the  history.  It  is  best  treated  by  complete  excision, 
and  this,  in  one  case  of  Allingham' s,  secured  immunity  for  a 
period  of  four  years  during  which  the  patient  was  under  obser- 
vation. 

Dysentery. — In  dysenteric  ulceration,  the  diseased  portion 
of  the  lower  bowel  becomes  infiltrated  with  fibrinous  exuda- 
tion, and,  as  a  result  of  the  compression  which  this  exercises,  is 
necrosed  and  sloughs.  When  the  slough  is  cast  off,  there 
results  a  loss  of  substance,  and  if  this  is  superficial,  the  mem- 
brane may  regain  its  former  state  ;  but,  if  deep,  the  usual 
callous  cicatrix  is  produced  in  its  place,  and  stricture  is  the 
result. 

The  ulcers  resulting  from  this  process  vary  much  in  size, 
location,  and  appearance.  They  may  be  minute  circles,  but  are 
generally  large,  and,  though  their  favorite  site  is  the  rectum  or 
sigmoid  flexure,  they  may  be  found  anywhere  in  the  large  in- 
testine. They  may  extend  so  as  to  coalesce  and  leave  only 
islands  of  mucous  membrane  between  the  extensive  patches. 
The"  process  usually  involves  only  the  mucous  coat,  but  may  ex- 
tend in  breadth,  and  result  in  perforation  and  its  attendant 
evils.    The  coats  of  the  bowel  may  become  sinuous  abscesses,  so 


252  DISEASES    OF   THE    RECTUM    AND    ANUS. 

that,  on  dividing  the  prominent  portion  of  mucous  membrane 
between  two  ulcers,  several  drachms  of  pus  may  escape  (Ha- 
bershon).  Although  all  the  symptoms  of  dysentery  may  result 
from  ulceration  due  to  other  causes,  as  in  Annandale's  case,1 
there  is  no  doubt  that  in  this  country  the  disease  is  one  of  the 
causes  of  chronic  ulceration  and  stricture,  and  Habershon  con- 
cludes that  the  disease  is  more  common  in  our  climate  than  is 
generally  supposed. 

In  the  "Medical  and  Surgical  History  of  the  War  of  the  Re- 
bellion," 5  Dr.  "Woodward  remarks  that  stricture  resulting  from 
dysenteric  ulceration  seems  to  have  been  much  rarer  than  might 
have  been  supposed,  and  that  no  case  has  been  reported  at  the 
Surgeon-General's  office,  either  during  the  war  or  since  ;  that 
the  Army  Medical  Museum  does  not  contain  a  single  specimen  ; 
nor  has  he  found  in  the  American  medical  journals  any  case 
substantiated  by  post-mortem  examination  in  which  this  condi- 
tion is  reported  to  have  followed  a  flux  contracted  during  the 
Civil  War.  In  the  Amer.  Journal  of  the  Medical  Sciences  for 
April,  1881,  I  published  a  case  which  I  then  believed  came  under 
that  category,  and  the  subsequent  history  of  which  has  only 
the  more  convinced  me  of  the  correctness  of  the  diagnosis. 

Venereal  Ulcers. — Gonorrhoea  of  the  rectum  has  already 
been  spoken  of  under  the  head  of  proctitis.  Without  attempt- 
ing to  decide  upon  the  specific  character  of  the  inflammation 
which  may  follow  the  contact  of  gonorrheal  virus,  it  may  be 
well  to  call  attention  to  the  severity  of  that  inflammation  and 
to  the  fact  that  it  may  cause  ulceration,  and,  probabty,  subse- 
quent stricture.  During  the  height  of  the  process  the  rectum 
is  hot,  red,  swollen,  and  granular,  and  there  is  an  abundant 
purulent  discharge  issuing  from  the  anus,  from  time  to  time,  in 
clots.  The  irritation  of  this  may  cause  erosions  and  fissures 
which  may  reach  a  considerable  size  ;  or  a  previously  existing 
fissure  may  become  inoculated  in  this  way  and  spread  in  extent. 

Chancroids. — One  of  the  most  frequent  of  all  the  superficial 
ulcerations  at  the  anus  is  the  soft  chancre.  It  is  said  by  Pean 
and  Malassez  to  have  constituted  nearly  one-half  of  all  the 
ulcerations  in  this  region  examined  at  the  Lourcine  in  1868. 
It  is  much  more  common  in  females  than  in  males,  consti- 
tuting one  in  nine  cases  of  chancroids  in  the  former  and  one  in 

1  Brit.  Med.  Journ.,  p.  681.     1872.  *  Part  II.,  vol.  i.,  Med.  Hist. 


NON-MALIGNANT    ULCERATION.  253 

four  hundred  and  forty-five  in  the  latter.1  To  account  for  this 
greater  relative  frequency  only  two  things  are  necessary :  the 
frequency  of  accidental  contact  of  the  male  organ  in  coition  and 
the  facility  of  auto-inoculation  which  is  due  to  the  proximity 
of  the  vulva  and  vagina. 

These  ulcers  are  seen  either  on  the  skin  around  the  anal 
orifice,  or  just  within  the  canal  (Plate  I.),  and  show  a  decided 
tendency  not  to  pass  above  the  upper  border  of  the  internal 
sphincter.  So  marked  is  this  trait  that  their  existence  in  the 
rectum  proper  has  been  denied,  and  the  mucous  membrane 
supposed  to  furnish  no  suitable  ground  for  their  imoculation. 
They  may  be  single  or  multiple,  may  be  situated  at  any  point 
in  the  anal  circumference,  or  may  completely  surround  it.  In 
one  case  of  my  own,  the  anus  was  completely  surrounded  by  a 
group  of  these  sores,  and  the  ulceration  extended  from  the 
posterior  commissure  backward  in  the  intergluteal  fold  its 
whole  length,  as  far  as  the  base  of  the  sacrum,  being  superficial, 
however,  in  the  whole  of  its  course.  In  such  a  case  the  pain  is 
apt  to  be  severe  ;  a  careful  examination  is  impossible  without 
ether,  and  there  is  often  free  haemorrhage.  The  bleeding  at  the 
time  of  defecation  was  the  chief  cause  of  alarm  to  the  patient 
in  the  case  mentioned.  These  sores  have  the  same  charac- 
teristics as  the  soft  chancre  in  other  parts  of  the  body.  The 
class  of  women  in  whom  they  occur  is  always  an  aid  to  the  diag- 
nosis, and  if  suspicion  as  to  their  nature  exists,  the  test  of  auto- 
inoculation  may  always  be  tried. 

Sores  of  this  variety  tend  to  spontaneous  cure  with  cleanli- 
ness, and,  if  necessary,  with  judicious  cauterization ;  and  no 
matter  how  completely  they  may  have  involved  the  anus  or  the 
skin  around  it,  they  seldom  leave  any  traces  of  their  former 
existence.  On  the  other  hand,  the  cure  may  be  delayed  even 
for  months,  and  the  sore  may  assume  a  chronic  type,  due  either 
to  the  existence  of  other  disease  in  the  rectum,  as  haemorrhoids, 
or  to  a  syphilitic  or  scrofulous  taint  in  the  patient.  They  may 
be  complicated  by  a  chronic  oedema  of  the  surrounding  parts, 
and  resemble  the  lupus  exedens  already  mentioned,  or  by  the 
gangrenous  process  known  as  phagedsena,  generally  of  the 
chronic  variety,  and  advancing  in  one  place  while  healing  in 
another. 

1  Fournier:   Diet,  de  Med.  et  Chirg.  Prat.,  Art.  Chancre,  p.  72. 


254  DISEASES    OF    THE    RECTUM    AND    ANUS. 

And  now  we  come  to  the  debatable  ground  upon  which  so 
much  has  been  said  and  written,  and  about  which  much  still 
remains  to  be  learned.  Do  these  soft  chancres  ever  cause  strict- 
ure of  the  rectum,  and  are  they  the  most  common  cause  of 
those  grave  strictures  so  often  met  in  women  who  have  had 
syphilis,  and  which  are  generally  known  as  S37philitic  %  In  the 
light  of  our  present  knowledge,  and  yet  subject  to  such  modifi- 
cations of  opinion  as  future  experience  may  teach,  we  shall  an- 
swer yes  to  the  first  of  these  questions,  and  no  to  the  second. 

That  a  soft  chancre  may  extend  into  the  rectum  and  cause 
great  destruction  of  tissue,  cicatrize,  and  leave  stricture,  is  be- 
yond doubt.  Van  Buren '  says,  "I  have  certainly  seen  this  in 
several  cases,  but  only  in  women;"  Bumstead  and  Taylor" 
speak  in  the  same  way  ;  Molliere3  says,  "Nevertheless,  the  soft 
chancre  of  the  rectum  does  exist,  and  has  even  been  seen  to  as- 
sume frightful  proportions  in  this  deep  region  ;"  and  Bridge's4 
case  is  generally  considered  as  conclusive,  though  its  authority 
rests  much  more  upon  the  well-known  character  of  the  men 
who  pronounced  judgment  upon  it  than  upon  its  history  as  it 
stands  recorded  ;  for  there  is  at  least  a  strong  suspicion  of 
syphilis,  and  there  is  no  account  of  the  crucial  test  of  auto- 
inoculation. 

Dr.  Mason's5  paper  to  prove  the  chancroidal  nature  of  this 
kind  of  ulceration  and  stricture  has  this  great  advantage  over 
the  similar  one  of  Gosselin,6  that  he  leaves  the  reader  in  no 
doubt  as  to  what  he  means  by  chancroid,  and  unhesitatingly 
adopts  the  dualistic  theory.  That  this  is  not  the  case  in  the 
latter  article  the  reader  may  readily  convince  himself  by  a 
careful  perusal ;  and,  for  my  own  part,  I  am  unable  to  see 
where  in  this  justly  celebrated  article  the  non-syphilitic  nature 
of  the  affection  in  question  is  taught,  for  the  author  leaves  us  in 
absolute  ignorance  as  to  which  of  the  two  at  present  well-known 
varieties  of  "chancre"  is,  in  his  opinion,  the  primary  cause  of 
the  stricture  ;  and  it  is  rather  by  inference  than  otherwise  that 
his  "chancre"  is  interpreted  to  mean  chancroid. 

The  idea  left  on  the  mind  of  the  reader  is  not  that  the  dis- 
ease is  not  syphilitic,  but  that  it  is  neither  a  primary,  secondary, 

1  Op.  cit.,  p.  243.  a  Venereal  Dis.,  Philadelphia,  1879. 

3  Op.  cit,  p.  G77.  *  Arch,  of  Dermatology,  January,  1876. 

6  American  Journal  of  the  Medical  Sciences,  January.  1873. 
«  Arch.  Gen.  deMed.,  1854. 


NON-MALIGNANT    ULCERATION.  255 

nor  tertiary  manifestation  of  syphilis,  as  such  are  generally  un- 
derstood, but  something  developed  in  the  neighborhood  of  the 
primary  sore. 

Gosselin,  though  he  comes  nearer  to  it  than  had  ever  been 
done  before,  just  missed  enunciating  the  chancroidal  nature  of 
these  strictures,  though  Bassereau  had  distinguished  between 
the  two  chancres  two  years  before.  What  he  does  assert  is,  that 
they  are  not  to  be  considered  as  manifestations  of  constitutional 
syphilis,  but  that  they  are  of  local  character,  "  due  to  a  special 
modification  of  the  vitality  of  the  tissues  contaminated  by  the 
virus  of  the  chancre,  comparable  to  the  lengthening  and  hyper- 
trophy of  the  prepuce  with  contraction  of  its  orifice,  which  fol- 
lows a  chancre  on  its  under  surface,  in  which  the  disease  is 
evidently  neither  an  oedema,  nor  a  specific  induration,  nor  a 
constitutional  affection,  but  a  local  lesion,  due  to  the  presence  of 
the  chancres,  and  consecutive,  to  the  inflammation  which  they 
have  caused."  In  the  same  class  of  lesions  he  places  hypertro- 
phy of  the  labia,  condylomata,  and  other  vegetations. 

The  weight  of  the  evidence,  then,  is  decidedly  in  favor  of  the 
occasional  causation  of  stricture  by  the  chancroid.  But  that  all 
of  the  many  so-called  syphilitic  strictures  are  not  due  to  this 
cause  is  rendered  certain  by  the  fact  that  many  of  them  occur 
in  women  above  the  suspicion  either  of  a  chancre  or  a  chan- 
croid, and  many  more  are  developed  late  in  the  course  of  true 
syphilis,  but  are  not  preceded  by  any  iilceration,  chancroidal 
or  otherwise,  at  the  anus,  and  have  their  starting-point  well 
above  the  sphincter  muscle.  Of  the  true  nature  of  these  we 
shall  speak  later. 

Chancre. — True  chancre  at  the  anus  is  not  very  uncommon. 
Though  Pean  and  Malassez  saw  only  one  case  at  the  Lourcine 
in  1868,  they  explain  the  fact  by  the  slight  local  disturbance 
which  the  sore  causes — so  slight  that  the  sufferers  do  not  seek 
treatment.  They  give  the  proportion  in  this  place  as  compared 
to  chancres  in  other  parts  of  the  body  as  one  in  sixty-eight,  and 
as  much  more  frequent  in  women  than  in  men  (one  in  thirteen 
in  the  former,  to  one  in  one  hundred  and  seventy-seven  in  the 
latter).  These  are  about  the  same  figures  reached  by  Jullien. 
In  the  female,  a  sore  in  this  locality  is  easily  accounted  for  by 
accidental  inoculation  ;  in  the  male,  it  means  sodomy.  They 
are  most  likely  to  be  mistaken  for  simple  fissures,  but  have  a 
hard,  raised  outline  and  indurated  base,  are  less  painful,  and 


256  DISEASES    OF   THE    RECTUM    AND    ANUS. 

devoid  of  the  healthy  surface  of  the  former.  In  any  case  of 
suspicion  constitutional  treatment  should  be  delayed  till  the 
diagnosis  is  completed  by  the  appearance  of  general  symptoms. 

True  chancre  within  the  rectum  is  very  rare  indeed.  Ricord, 
Fournier,  and  Vidal  de  Cassis  each  report  a  single  case,  and  in 
the  latter  the  induration  is  said  to  have  been  so  great  as  to 
cause  stricture.1  Molliere  carefully  analyzes  the  evidence  on 
this  point  up  to  date,  and  concludes  that  though  a  true  chancre 
may  exist  within  the  rectum,  it  never  causes  stricture,  for  the 
reason  that  it  does  not  produce  any  great  amount  of  ulceration, 
and  that  the  induration  tends  to  spontaneous  resolution,  or,  at 
least,  rapidly  yields  to  the  influence  of  mercury.  The  diffi- 
culties surrounding  the  diagnosis  of  such  a  sore  are  manifest. 
Its  mere  appearance  would  scarce  be  conclusive,  and  in  women 
the  absence  of  any  other  sore  which  might  cause  secondary 
symptoms  would  need  to  be  absolutely  proved — a  very  difficult 
thing  to  do. 

Secondary  and  Tertiary  Syphilis. — One  of  the  secondary 
manifestations  of  syphilis  is  to  be  looked  for  at  the  anus  and 
rectum — the  mucous  patch,  not  an  infrequent  sign  in  the  former 
locality,  and  one  liable  to  assume  ulcerative  action  from  local 
irritation  or  inoculation  with  the  virus  of  the  chancroid.  Gen- 
erally, however,  they  are  devoid  of  symptoms,  and  disappear 
spontaneously  without  treatment,  or  simply  with  cleanliness 
and  the  use  of  an  astringent  wash.  That  the  mucous  patch 
may  appear  in  the  rectal  pouch  also  is  rendered  probable  from 
analogy  with  the  fauces,  and  such  cases  have  been  reported  ; a 
but  as  they  never  form  cicatrices,  they  must  be  counted  out  of 
the  etiology  of  stricture. 

Tertiary  Syphilis. — Well-marked  cases  of  tertiary  syphilitic 
ulceration  in  the  rectum,  such  as  are  seen  in  the  mouth  and 
throat,  are  seldom  mentioned  ;  and  yet  that  they  may  exist  and 
may  cause  extensive  destruction  is  not  only  probable  from  anal- 
ogy, but  clinically  true.  Smith3  says,  "I  am  strongly  im- 
pressed with  the  view  that  stricture  of  the  rectum  is  produced 
either  directly  by  the  specific  ulceration  in  the  part  affected,  or 
by  contact  of  the  discharge  from  the  surrounding  parts" — a 
sentence  of  which  the  last  clause  weakens  the  first,  for  the  ques- 
tion is  not  whether  ulceration  may  be  set  up  in  the  rectum  of  a 


1  Van  Buren.  *  Molliere,  p.  641.  3  Diseases  of  the  Rectum. 


NON-MALIGNANT    ULCERATION.  257 

syphilitic  person  by  the  irritation  of  a  discharge  from  the  sur- 
rounding parts,  but  whether  there  is  such  a  thing  as  true  ter- 
tiary syphilitic  ulceration  of  the  rectum. 

Curling '  describes  a  case  presented  by  the  late  Mr.  Avery 
at  a  meeting  of  the  London  Pathological  Society,8  which  he 
says  clearly  showed  the  connection  of  the  lesion  with  syph- 
ilis. "  Immediately  within  the  anus,  which  was  surrounded  by 
a  circle  of  vegetations,  the  ulcer  commenced  extending  three 
inches  upward,  and  occupying  the  whole  of  the  internal  surface 
of  the  rectum  to  that  extent.  The  edges  were  rough  and  un- 
even above,  and  below  soft  and  rounded,  the  whole  surface  was 
smooth,  exhibiting  the  muscular  fibres  of  the  intestine  quite 
bare.  The  patient  died  with  numerous  indelible  marks  of  syph- 
ilitic eruption  on  the  limbs  and  trunk." 

Paget 3  also  describes  a  case  very  fully  and  gives  the  main 
points  by  which  syphilitic  ulcers  may  be  distinguished  from 
tubercular.  He  says:  "The  whole  mucous  membrane  is  de- 
stroyed except  one  small  patch,  which  is  thickened  and  opaque. 
The  exposed  submucous  surface  has  a  lowly  tuberculated,  un- 
dulating, uneven  appearance,  and  is  thickened  by  infiltration. 
In  the  early  stages  the  tissue  is  soft,  as  it  is  from  recent  inflam- 
matory effusion  or  oedema ;  but  as  the  infiltration  organizes  it 
hardens,  becoming  callous,  with  fusion  of  the  mucous  and  sub- 
mucous coats,  and  then  contracts  and  thus  brings  about  the 
stricture.  The  affection  commonly  extends  from  the  anus,  as 
if  by  continuity  with  the  excrescence  (condylomata),  to  about 
five  inches  up  the  rectum  ;  but  it  is  rarely  so  marked  in  the  first 
inch  of  the  rectum  as  it  is  higher  up." 

In  the  case  spoken  of  there  were  also  ulcers  in  the  colon, 
which,  as  the  patient  died  of  phthisis,  had  to  be  carefully  dis- 
tinguished from  tubercular  disease.  He  says  :  "  On  the  mucous 
membrane  of  all  parts  of  the  colon  there  are  ulcers,  of  regular 
round  or  oval  shape,  from  one-sixth  to  two-thirds  of  an  inch  in 
diameter,  with  clean,  sharply  cut,  scarcely  thickened  edges, 
surrounded  by  healthy  or  only  too  vascular  mucous  membrane. 
Their  bases  are  for  the  most  part  level,  flat,  or  with  low  granu- 
lations resting  on  the  submucous  tissue,  nowhere  penetrating 
to  the  muscular  coat,  with  no  marked  subjacent  thickening  or 

1  Diseases  of  the  Rectum,  p.  112. 

2  Transactions  of  the  Pathological  Society,  vol.  i.,  p.  94. 

3  Medical  Times  and  Gazette,  1,  p.  279.     1865. 
17 


258 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


hardening.  On  some  of  them  are  ramifying  blood-vessels  ;  on 
some  few  there  is  at  the  centre  of  the  base  a  small  island  of 
mucous  membrane,  giving  to  the  ulcer  an  evident  likeness  to 
the  annular  syphilitic  ulcer  of  the  skin."  In  a  few  places  they 
had  coalesced  so  that  the  annular  shape  was  less  distinct.  In 
the  colon  they  were  continuous  with  those  in  the  rectum  which 


'"  £0$  ;cp 


Fir;.  77.— Syphilitic  Ulceration  of  Colon.  (Huet.)  a,  swollen  follicles  with  gummy  infil- 
tration ;  b,  commencing  ulceration  of  follicle  ;  c,  ulcer  showing  submuoous  connective  tissue  ; 
d,  ulcer  exposing  muscular  layer. 

Paget  conjectures  to  have  been  originally  of  the  same  shape. 
Fig.  77. 

The  diagnostic  marks  are  thus  given:  "These  ulcers  were 
limited  to  the  large  intestine  and  decrease  in  size  and  number 
from  the  rectum  upward — conditions  which  I  think  are  never 
observed  in  tubercular  disease.  There  is  not  a  trace  of  tubercle, 
i.e..  of  circumscribed,  crude,  or  softening  tuberculous  deposit, 


NON-MALIGNANT    ULCERATION.  259 

in  the  submucous  or  any  other  tissue  of  the  intestine,  none  in  a 
Peyer'  s  patch,'  or  at  the  base  or  edge  of  any  ulcer,  or  in  the 
sub-peritoneal  tissue  below  an  ulcer.  The  shape  and  other 
characteristics  of  the  ulcers  are  quite  unlike  those  of  intestinal 
tuberculosis ;  they  are  regular,  with  sharp,  even,  well-defined 
edges,  with  level  bases  ;  they  are  not  excavating,  nor  do  they 
extend  through  the  submucous  tissue  ;  their  edges  are  nowhere 
eroded  or  undermined,  sinuous,  thickened,  or  brawny  or  infil- 
trated ;  the  subjacent  and  intervening  structures  appear  healthy 
except  at  the  rectum.  These  ulcers  are  not  grouped,  and  where 
by  extension  or  coalescence  they  have  lost  their  firgt  shapes 
they  have  acquired  one  altogether  irregular,  and  have  in  no  in- 
stance even  tended  toward  that  girdle -like  shape,  encircling  the 
canal  of  the  intestine,  which  is  so  characteristic  in  the  large 
coalesced  tuberculous  ulcer.  Thus  by  negative  as  well  as  by 
positive  characters,  these  ulcers  are  clearly  distinguished  from 
the  tuberculous,  and,  as  I  have  said,  there  is  no  other  form  of 
intestinal  ulcer  to  which  they  bear  even  a  remote  resemblance." 

I  have  seen  two  cases  of  ulceration  in  syphilitic  women 
where  I  could  find  no  more  satisfactory  explanation  of  the  cause 
than  the  presence  of  this  constitutional  state.  In  both  the 
disease  began  well  within  the  rectum  and  not  at  the  anus, 
which  is  rare  but  which  proves  that  they  were  not  an  upward 
extension  of  a  chancroidal  ulcer  at  the  anus ;  and  in  both  it 
began  as  an  ulcer  of  the  mucous  membrane,  and  was  not  at  all 
similar  to  what  has  been  described  as  ano-rectal  syphiloma.  In 
one  it  coincided  with  a  late  syphilitic  eruption,  but  though  the 
eruption  promptly  yielded  to  general  treatment,  the  rectal  dis- 
ease did  not. 

A  strong  argument  in  favor  of  the  syphilitic  origin  of  many 
cases  of  ulceration  and  stricture  is  found  in  the  fact  that  a  large 
proportion  of  them  all,  nearly  one-half,  occur  in  persons  with  an 
undoubted  syphilitic  history. 

Both  Smith  and  Paget  remark  on  the  occurrence  of  large 
condylomatous  tags  of  skin  around  the  anus  in  these  cases  as  a 
sign  of  value  in  the  diagnosis  of  syphilis  ;  and  the  former  re- 
marks that  he  has  more  than  once  made  the  diagnosis  of 
syphilitic  stricture  from  their  presence  alone.  As  a  sign  of 
ulceration  and  probable  stricture  they  are  of  value  ;  but  they 
can  hardly  be  said  to  point  to  the  character  of  the  ulceration. 

The  ano-rectal  syphiloma  of  Fournier  (see  non-malignant 


260  DISEASES    OF    THE    RECTUM    AND    ANUS. 

growths)  is  not  primarily  an  ulceration,  but  like  the  gummata 
it  leads  to  ulceration,  and  according  to  him  it  is  the  most 
common  cause  of  that  form  of  stricture  which  is  called  syphilitic 
and  which  we  have  spoken  of  in  connection  with  the  chancroid. 
It  is  primarily  an  infiltration  of  the  wall  of  the  rectum  by  a  new 
deposit  of  peculiar,  doughy,  inelastic  feel,  covered  by  shiny, 
livid  integument,  which  is  prone  to  break  down  into  ulceration  ; 
and  it  causes  stricture,  not  by  a  process  of  ulceration  and  sub- 
sequent cicatrization,  but  by  an  actual  blocking  up  of  the  outlet 
of  the  canal. 

Stricture. — Not  only  is  ulceration  a  common  cause  of  strict- 
ure, but  any  form  of  stricture  is  liable  by  its  obstructive  action 
to  set  up  ulceration  in  the  wall  above. 

At  first  there  is  dilatation  of  the  rectal  pouch  and  hyper- 
trophy of  its  walls,  due  to  the  effort  to  overcome  the  obstruc- 
tion. In  this  way  the  coats  may  become  double  their  natural 
thickness.  Next  an  ulcerative  action  is  set  up  in  the  mucous 
membrane,  probably  due  to  the  irritation  and  traumatism  of 
fjeces.  Beginning  as  a  simple  congestion,  it  advances  to  com- 
plete destruction  of  the  tissue  over  the  whole  circumference  of 
the  bowel,  and  sometimes  for  several  inches  above  the  stricture. 
As  a  result  of  this  process  the  muscular  layer  may  be  entirely 
denuded,  and  even  perforated  at  a  point  high  above  the  original 
disease.1 

Gangrene. — The  gangrene  which  sometimes  follows  the  con- 
tinued fevers  and  is  particularly  liable  to  affect  the  female 
genitals,  and  the  more  severe  forms  of  abscess  in  this  region 
may  by  their  extensive  sloughing  end  in  subsequent  deform- 
ity and  stricture.  The  following  case2  shows  the  extent  of  the 
ravages  which  may  be  caused  in  this  way. 

Case  XVIII.  Gangrene. — Colored  woman,  aged  eighteen 
years,  stated  that  six  days  before  she  had  been  taken  in  labor 
at  full  term,  and  was  delivered  of  her  first  child  after  an  easy 
labor  of  less  than  twelve  hours.  She  was  left  after  delivery  in 
a  soiled  condition  upon  the  filthy  bed  for  three  or  four  days, 
when  she  experienced  some  uneasiness  and  felt  some  pimples 
upon  the  vulva.  On  examination  on  admission  to  the  hospital, 
the  labia  were  found  swollen,  black,  and  sloughing  ;  and  escap- 

1  See  Molliere,  p.   294;  Gosselin,  loc.   cit.;   Lancereaux,  Bull,  de  la   Soc.  Anat., 
1859;  Malassez,T>ict.  Encyc.,  p.  728. 

8  Dr.  Sparkman,  Trans.  South  Carolina  Med.  Ass.,  1879. 


NON-MALIGNANT    ULCERATION.  261 

ing  between  them  was  a  purulent  discharge  of  intensely  foetid 
odor,  mixed  with  the  urine  which  constantly  trickled  away. 
With  this  local  condition  there  was  associated  a  slight  fever 
and  small,  quick  pulse.  Eight  days  after  admission,  the  whole 
vulva  and  vagina,  which  had  separated  at  its  junction  with 
the  uterus,  were  thrown  off,  leaving  a  deep  excavation,  five 
inches  from  above  downward,  two  and  a  half  inches  across,  and 
three  inches  in  depth.  The  greater  portion  of  the  back  of  the 
cavity  was  filled  with  a  globular  body,  red  and  bleeding  when 
touched,  which  was  taken  for  the  bladder.  In  the  lower  por- 
tion of  the  cavity  a  remnant  of  the  posterior  wall  of  the  rectum 
which  had  suffered  in  the  general  destruction  could  be  seen. 
The  slough  which  came  away  was  nearly  eight  inches  in  length 
and  two  or  three  in  thickness. 

This  disease  is  not  to  be  confounded  with  the  idiopathic 
gangrenous  cellulitis  already  spoken  of  under  the  head  of 
abscess,  and  which  is  also,  when  recovery  takes  place,  very  apt 
to  result  in  subsequent  deformity  and  stricture. 

Symptoms. — The  symptoms  of  what  is  known  as  the  irrita- 
ble ulcer  or  fissure  are  so  well  marked  as  to  render  its  diagnosis 
in  most  cases  easy.  The  chief  is  the  peculiar  pain,  which  may 
be  constant,  but  is  always  increased  by  defecation.  The  act  of 
defecation  itself  may  not  be  notably  painful,  but  after  the  act, 
sometimes  almost  immediately,  sometimes  after  a  short  interval, 
the  characteristic  suffering  begins  and  may  last  in  mild  cases 
an  hour  or  two,  or  in  severe  ones  nearly  all  of  the  twenty-four 
hours.  The  pain  is  described  by  the  sufferers  as  dull  gnawing 
and  aching  rather  than  lancinating,  and  with  it  there  will  often 
be  associated  neuralgic  pain  in  the  loins  and  down  the  thighs. 

As  a  result  of  this  suffering,  at  first  periodic  and  later  con- 
stant, a  very  miserable  general  condition  is  often  developed. 
The  sufferer  soon  learns  to  dread  the  act  of  defecation  and  to 
postpone  it  as  long  as  possible,  till  a  state  of  chronic  constipa- 
tion is  produced  which  is  overcome  at  long  intervals  by  purga- 
tives ;  and  in  this  way  the  whole  digestive  apparatus  is  thrown 
out  of  order.  In  women  also  there  is  apt  to  be  reflex  irritation 
of  the  bladder  with  tenesmus  ;  and  in  men  there  may  be  spas- 
modic stricture  of  the  urethra.  In  women,  also,  it  is  not  un- 
common to  find  uterine  trouble  combined  with  that  at  the  anus. 
It  is  sometimes  a  matter  of  amazement  to  the  physician  to  see 
how  long  a  woman  will  suffer  from  a  simple  sore  of  this  kind, 


2G2  DISEASES    OF    THE    RECTUM    AND    ANUS. 

and  to  what  a  condition  of  invalidism  she  will  allow  herself  to 
be  reduced  before  she  will  seek  for  aid.  The  struggle  between 
feminine  modesty  and  the  desire  for  relief  may  last  for  many 
years  before  common  sense  finally  gains  the  victory. 

It  will  sometimes  be  found  that  as  great  suffering  may  be 
caused  by  a  simple  erosion  at  the  anus  as  by  more  extensive 
and  deeper  ulceration,  and  indeed  the  amount  of  pain  is  not  at 
all  indicative  of  the  depth  or  extent  of  the  sore.  The  element 
upon  which  the  pain  directly  depends  is  probably  the  exposure 
of  nerve-filaments.  Moreover,  the  susceptibility  to  pain  varies 
greatly  in  different  people,  and  a  woman  of  high  nervous  or- 
ganization may  be  completely  invalided  by  a  sore  which  would 
not  prevent  a  laboring  man  from  attending  to  his  daily  avoca- 
tions. 

It  must  be  remembered  in  this  connection  that  all  fissures  or 
ulcers  in  this  part  are  not  painful,  that  many  heal  sponta- 
neously, and  many  more  exist  for  years  without  causing  any 
particular  trouble. 

Ulceration  within  the  rectum  is  also  attended  by  a  certain 
train  of  symptoms  which  render  its  existence  extremely  prob- 
able, and  which  in  themselves  are  sufficient  to  denote  the  pres- 
ence of  an  ulcerative  process,  though  throwing  little  light  upon 
its  nature.  These  have  been  so  well  described  by  Allingham 
that  we  cannot  do  better  than  give  them  in  his  own  words  : 

"In  the  majority  of  these  cases  the  earliest  symptom  is 
morning  diarrhoea,  and  that  of  a  peculiar  character,  in  my 
opinion,  quite  indicative  of  the  disease  [ulceration],  and  can 
only  be  confounded  with  cancer.  The  patient  will  tell  you  that 
the  instant  he  gets  out  of  bed  he  feels  a  most  urgent  desire  to 
go  to  stool ;  he  does  so,  but  the  result  is  not  satisfactory.  What 
he  passes  is  generally  wind,  a  little  loose  motion,  and  some  dis- 
charge resembling  'coffee-grounds'  both  in  color  and  consist- 
ency ;  occasionally  the  discharge  is  like  the  '  white  of  an  un- 
boiled egg'  or  'a  jelly-fish,'  more  rarely  there  is  matter.  The 
patient  in  all  probability  has  tenesmus,  and  does  not  feel  re- 
lieved ;  there  is  something  of  a  burning  and  uncomfortable 
sensation,  but  not  actual  pain  ;  before  he  is  dressed  very  likely 
]i<-  has  again  to  seek  the  closet ;  this  time  he  passes  more 
motion,  often  lumpy,  and  occasionally  smeared  with  blood.  It 
also  may  happen  that  after  breakfast,  taking  hot  tea  or  coffee, 
the  bowels  will  again  act ;  after  this,   he  feels  all  right,  and 


NON-MALIGNANT    ULCERATION.  263 

goes  about  his  business  for  the  rest  of  the  day,  only  perhaps 
being  occasionally  reminded  by  a  disagreeable  sensation  that 
he  has  something  wrong  with  his  bowel.  .  .  .  After  this 
condition  has  lasted  for  some  months,  more  or  less,  as  influ- 
enced by  the  seat  of  the  ulceration  and  the  rapidity  of  its  ex- 
tension, the  patient  begins  to  have  more  burning  pain  after  an 
evacuation,  there  is  also  greater  straining  and  an  increase  in 
the  quantity  of  discharge  from  the  bowel  ;  there  is  now  not 
so  much  jelly-like  matter,  but  more  pus — more  of  the  coffee- 
ground  discharge  and  blood.  The  pain  suffered  is  not  very 
acute,  but  very  wearying,  described  as  like  a  dull  toothache, 
and  it  is  induced  now  by  much  standing  about  or  walking.  At 
this  stage  of  the  complaint,  the  diarrhoea  comes  on  in  the  even- 
ing as  well  as  the  morning,  and  the  patient's  health  begins  to 
give  way,  only  triflingly  so  perhaps,  but  he  is  dyspeptic,  loses 
his  appetite,  and  has  pain  in  the  rectum  during  the  night  which 
disturbs  his  rest ;  he  also  has  wandering  and  apparently  anoma- 
lous pains  in  the  back,  hips,  down  the  legs,  and  sometimes  in 
the  penis." 

We  need  scarcely  call  attention  to  the  extreme  gravity  of 
this  condition,  or  to  the  certainty  with  which,  if  untreated, 
and  sometimes  indeed  in  spite  of  the  best  treatment,  it  will  end 
either  fatally,  or  in  stricture  which  will  require  the  gravest 
surgical  procedures  for  its  relief.  The  picture  is  unfortunately 
a  familiar  one  to  every  general  practitioner,  and  a  case  of  severe 
or  extensive  ulceration  of  the  rectum,  is  perhaps  one  which  calls 
for  as  much  skill  in  treatment  and  yields  as  poor  results  as  any- 
thing in  the  range  of  surgery. 

Diagnosis. — The  diagnosis  of  the  existence  of  ulceration  is 
generally  easy  with  sufficient  care.  A  small  ulcer  within  the 
grasp  of  the  external  sphincter,  or  partially  concealed  within 
one  of  the  saccnli,  may  easily  escape  a  cursory  examination, 
but  no  ulceration  within  four  inches  of  the  anus  is  beyond  the 
reach  of  actual  touch  and  vision,  and  none  need,  therefore, 
escape  detection  when  the  examination  is  properly  conducted. 
In  many  cases  the  diagnosis  is  plain,  the  sphincter  will  be 
found  destroyed,  and  the  rectum  and  vagina  will  present  one 
common  cavity  of  foul  appearance,  from  which  issues  a  foetid 
purulent  discharge.  In  other  cases,  by  a  careful  and  gentle 
pulling  apart  of  the  lips  of  the  anus  and  a  gentle  straining 
down  on  the  part  of  the  patient,  a  small  ulcer  within  the  grasp 


2G4  DISEASES    OF    THE    RECTUM    AND    AXES. 

of  the  sphincter,  or  at  least  its  lower  edge,  will  be  brought  into 
view  without  the  use  of  the  speculum  or  ether.  In  others,  a 
digital  examination  will  reveal  an  eroded  painful  spot  within 
the  rectum,  and  when  the  finger  is  withdrawn,  it  will  be  found 
stained  with  blood.  In  all  such  cases  the  diagnosis  is  easy  ;  in 
others,  there  is  but  one  way  to  make  a  diagnosis,  and  the  secret 
of  success  will  be  found  in  the  two  words — ether  and  the  specu- 
lum. This  is  the  way.  I  am  sorry  to  say,  which  is  least  often 
followed  by  the  general  practitioner.  It  is  much  easier  to  give 
a  lady  a  diarrhoea  mixture  and  trust  in  Providence  for  a  cure 
than  to  gain  her  consent  to  take  ether  and  be  thoroughly  exam- 
ined, and  for  this  reason  many  a  case  of  curable  disease  has  been 
allowed  to  reach  an  incurable  stage  before  its  existence  has  been 
certainly  determined.  The  existence  of  a  chronic  diarrhoea,  or 
of  a  discharge  of  any  kind  from  the  rectum,  is  always  a  good 
and  sufficient  reason  for  a  thorough  physical  examination,  and 
with  ether,  a  dilated  sphincter,  and  a  good  speculum,  no  one 
need  be  in  doubt  as  to  the  existence  of  ulceration  in  the  lower 
part  of  the  rectum. 

The  existence  of  ulceration  being  decided,  its  nature  remains 
to  be  determined.  We  have  already,  in  speaking  of  the  differ- 
ent varieties,  given  some  of  the  chief  points  in  the  differential 
diagnosis,  and  to  these  we  must  again  refer  the  reader.  In 
every  case  the  history  must  be  taken  into  account,  as  well  as 
the  appearance  of  the  lesion.  Of  the  many  varieties  we  have 
mentioned,  some  may  almost  certainly  be  excluded  from  their 
great  rarity.  Amongst  these  are  the  true  chancre,  the  tuber- 
cular deposit,  lupus,  and  rodent  ulcer.  In  the  majority  of 
cases,  after  excluding  syphilis,  the  ulcer  will  be  of  the  simple 
variety  first  described,  modified  more  or  less  by  the  general 
condition  of  the  patient,  or  it  will  be  malignant. 

TreaJbment. — In  speaking  of  the  treatment  of  ulceration  of 
the  rectum  and  anus,  we  will  first  deal  with  the  simplest  form, 
the  irritable  ulcer,  and  then  with  the  more  severe,  postpon- 
ing the  question  of  stricture,  which  is  the  most  frequent  result 
of  severe  ulceration,  to  a  separate  chapter. 

The  treatment  of  fissures  at  the  anus  should  in  the  first  place 
be  preventive  in  those  persons  in  whom  the  skin  of  the  part  is 
sensitive  and  liable  to  cracks  and  small  sores ;  and  for  such 
there  is  nothing  better  than  the  daily  washing  of  the  part  with 
cold  water  and  a  soft  sponge,  and  the  avoidance  of  anything 


NON-MALIGNANT    ULCERATION.  265 

which  may  tend   to  irritate  it,   such  as  the  use  of  printed  or 
rough  paper  after  defecation. 

When  fissures  really  exist,  but  before  the  sphincter  has  be- 
come irritable,  they  may  often  be  cured  by  a  nightly  applica- 
tion of  Goulard's  liniment  on  a  pledget  of  lint,  or  by  gently 
touching  the  surface  with  a  solution  of  nitrate  of  silver  to  coat 
the  sore  (gr.  v.  or  x. —  |j.).  Allingham  strongly  recommends 
the  following  ointment  for  use  in  such  cases,  to  be  applied  sev- 
eral times  during  the  day. 

B  Hyd.  subchlor gr.  iv. 

Pulv.  opii , gr.  ij. 

Ext.  belladonnas gr.  ij. 

Ungt.  sambuci 3    j. 

I  have  been  surprised,  in  my  own  practice,  at  the  remarkable 
results  which  can  be  obtained  in  simple  fissures  with  applica- 
tions of  weak  solutions  of  nitrate  of  silver,  and  I  have  the  notes 
of  many  cures  by  this  means,  some  of  them  by  a  single  applica- 
tion, combined  with  a  light  laxative  to  ensure  easy  passages. 

The  occasional  light  application  of  the  solid  stick  of  nitrate 
of  silver  will  sometimes  effect  a  cure,  but  cauterization  should 
be  used  with  great  caution.  ■  An  ointment  of  the  oxide  of  mer- 
cury ( 3  ss. —  fj.)  will  sometimes  prove  effectual,  and  I  have 
myself  been  very  well  satisfied  with  the  results  obtained  by  the 
occasional  passage  of  a  simple  hard  bougie  well  oiled,  and  al- 
lowed to  remain  a  few  minutes  within  the  anus.  "With  these 
means  at  my  disposal  I  now  seldom  find  a  fissure  which  can- 
not be  cured  by  milder  means  than  stretching  the  sphincter. 

With  these  local  measures  must  always  be  combined  the 
greatest  possible  amount  of  rest,  and  the  daily  administration 
of  a  mild  laxative  to  insure  a  soft  evacuation.  If  there  is 
already  considerable  pain  after  defecation,  it  is  a  good  plan  to 
have  the  bowel  emptied  before  going  to  bed  at  night,  and  to  ad- 
minister an  opium  suppository  or  enema  after  the  motion,  by 
which  means  a  quiet  night  may  often  be  obtained.  An  oint- 
ment of  ext.  belladonna  may  also  be  used  for  the  same  purpose. 

The  method  of  cure  which  at  the  present  time  has  succeeded 
all  others  in  these  cases,  and  which  is  so  invariably  successful 
as  to  leave  little  to  be  desired,  consists  in  temporarily  paralyzing 
the  sphincter  muscle  by  stretching  it,  the  patient  being  under 


266  DISEASES    OF   THE    EECTUM    AND    ANUS. 

ether.  This  is  an  outgrowth  of  the  original  operation  of  Boyeiy 
which  consisted  in  completely  dividing  the  muscle  with  the 
knife.  Syme  saw  that  this  was  unnecessary,  and  substituted 
for  it  the  division  of  those  fibres  of  the  muscle  which  formed 
the  base  of  the  ulcer,  an  operation  equally  effectual  and  in 
every  way  preferable  to  the  other,  involving  no  danger  of  per- 
manent loss  of  power  of  the  muscle,  inasmuch  as  its  fibres  are 
not  completely  divided.  Dumarquay3  also  proposed  another 
substitute,  which  he  believed  would  succeed  where  other  meas- 
ures failed,  and  which  consists  in  a  subcutaneous  section  of  the 
muscle  by  passing  the  knife  first  between  the  mucous  mem- 
brane and  the  muscle  and  then  catting  till  the  muscle  gave  way, 
very  much  as  the  tendo  Achillis  may  be  felt  to  do  when  sim- 
ilarly operated  upon.  The  objections  to  this  procedure  are  the 
occasional  occurrence  of  suppuration  in  spite  of  the  greatest 
care ;  and  the  risk  of  a  concealed  haemorrhage,  which  may  be 
none  the  less  severe  and  infiltrate  the  parts  with  blood. 

The  operation  of  stretching  was  originally  performed  by 
Recamier,  and  as  performed  by  him  consisted  rather  in  a  thor- 
ough kneading  of  the  muscle  with  the  fingers  than  in  stretch- 
ing ;  and  this  was  once  again  improved  upon  by  Maisonneuve  3 
who  brought  it  to  essentially  its  present  condition.  This  oper- 
ation has  been  already  described. 

In  fissures  complicated  with  polypi,  the  polypus  must  always 
be  removed  at  the  time  of  the  operation  ;  and  in  women  suffer- 
ing from  the  union  of  uterine  and  vesical  trouble  with  painful 
ulcer,  the  uterus  must  be  treated  as  well  as  the  ulcer,  or  the 
operation  on  the  latter  will  be  apt  to  fail. 

In  cases  where  the  patient  refuses  to  take  ether,  the  opera- 
tion of  drawing  a  sharp  knife  through  the  ulcer  and  muscular 
fibres  directly  beneath  it  may  sometimes  be  performed  quickly, 
and  with  only  momentary  pain.  It  is  customary  to  use  a  fenes- 
trated speculum  in  such  an  operation,  but  it  may  easily  be  dis- 
pensed with  when  a  straight,  blunt-pointed  knife  is  used.  The 
knife  should  be  very  sharp,  and  the  operation  must  be  skilfully 
done,  but  when  properly  done  it  is  usually  successful. 

It  is  not  necessary  to  cut  entirely  through  the  sphincter,  and 
yet  those  fibres  of  it  which  form  the  base  of  the  ulcer  should  be 

1  Traitc  des  Maladies  Chirurg.,  etc.,  t.  x.,  Paris,  1831. 
2  Arch.  Genl.  de  Mod.,  1840.  3  Clin.  Chirurg.,  t.  ii.,  p.  1864. 


NON-MALIGNANT    ULCERATION.  267 

fairly  divided,  for  it  is  by  putting  an  end  to  the  contractions  of 
these  fibres  that  the  operation  works  its  cure.  The  operation 
should  always  be  extensive  enough  to  produce  a  certain  amount 
of  relaxation  of  the  muscle. 

The  most  frequent  cause  of  failure  in  any  of  the  procedures 
commonly  employed  for  the  cure  of  fissure  is  the  presence  of  a 
small  polypus  or  an  external  hemorrhoidal  tag  in  connection 
with  the  sore.  These  should  always  be  searched  for  with  great 
care,  hence  with  a  speculum,  and  should  always  be  removed 
when  found.  Otherwise  neither  stretching  nor  division  of  the 
sphincter  will  be  of  much  avail. 

Note.—  Kjellberg  (Nordiskt  Med.  Arkiv,  Bd.  VIII. ,  Heft  4)  has  called  attention 
to  the  comparative  frequency  with  which  fissure  is  met  with  in  children,  which  he 
believes  to  be  much  greater  than  is  generally  supposed.  In  9,098  children  brought  to 
the  Polyklinik  of  Stockholm,  it  was  found  128  times  ;  60  of  the  cases  were  boys  and 
68  girls.  The  majority  were  under  one  year  of  age,  and  73  under  four  months.  The 
symptoms  resemble  those  in  the  adult,  but  are  less  severe,  and  the  treatment  is  the 
same,  care  being  taken  to  remove  anything  which  may  act  as  a  cause  of  the  trouble, 
such  as  constipation,  worms,  rectal  catarrh,  etc 

The  treatment  of  ulceration  within  the  rectum  is  a  much 
more  difficult  matter  than  the  treatment  of  that  at  the  anus, 
and  yet  in  principle  they  are  the  same.  In  both  we  give  the 
ulcer  rest,  and  try  to  assist  nature  in  her  own  methods  by 
avoiding  anything  which  shall  interfere  with  the  process  of  re- 
pair. The  treatment  of  ulcer  of  the  rectum  may  therefore  be 
summed  up  in  two  words,  rest  in  bed  and  fluid  diet.  I  do  not 
think  I  exaggerate  when  I  say  that  these  alone  will  cure  most 
cases  that  are  curable,  and  that  without  them  no  treatment  is 
likely  to  be  of  much  avail. 

The  rest  in  bed  must  be  absolute,  and  is  not  such  rest  as  is 
usually  considered  by  ladies  to  be  compatible  with  a  morning 
bath,  a  rather  elaborate  toilet  while  standing  before  the  mirror 
and  walking  round  the  room,  and  a  final  sitting  down  to  com- 
parative quiet  in  an  easy-chair  or  on  a  lounge  for  a  part  of  the 
day  till  the  reverse  of  the  performance  is  repeated.  Rest  in 
these  cases  means  rest  in  bed  for  weeks  at  a  time,  and  the  line 
should  be  drawn  on  exercise  at  just  what  is  necessary  for  the 
use  of  the  commode  which  is  brought  into  the  room  and  placed 
by  the  patient's  bed  when  necessary.  After  considerable  ex- 
perience I  have  found  it  easier  to  begin  right  in  these  cases  than 
to  waste  a  couple  of  months  while  the  patient  is  half  resting, 


268  DISEASES    OF   THE    RECTUM    AND    ANUS. 

and  then  have  to  come  to  it  in  the  end ;  and  have  again  and 
again  been  surprised  to  see  how  quickly  reparative  action  will 
begin  in  the  one  case,  and  how  long  it  may  be  delayed  in  the 
other.  An  hour's  walking  and  standing  around  the  sick-room 
will  undo  more  than  the  other  twenty- three  can  gain. 

This  point  being  carried  to  the  surgeon's  satisfaction,  the 
milk-diet  need  not  be  so  absolute;  but  may  be  varied  with 
soups  and  easily  digested  solids,  as  bread  and  crackers ;  care 
being  taken  to  secure  soft  and  unirritating  passages.  With 
such  diet  as  this  it  will  sometimes  happen  that  a  movement  of 
the  bowels  every  two  or  three  days  will  be  all  that  nature  re- 
quires, and,  as  long  as  such  a  condition  causes  no  uneasiness,  I 
am  not  accustomed  to  interfere  with  it  by  laxatives. 

In  cases  where  it  is  well  borne,  cod-liver  oil  may  be  adminis- 
tered both  as  food  and  laxative,  often  with  excellent  effect  upon 
the  general  condition  and  the  local  trouble. 

In  the  way  of  local  applications  suppositories  answer  the 
best  purpose.  The  menstruum  should  be  of  some  substance 
which  may  be  easily  dissolved  at  the  temperature  of  the  body  ; 
and  in  the  way  of  drugs  I  have  had  more  satisfaction  with 
bismuth  and  iodoform  than  with  anything  else.  The  practice 
of  introducing  local  remedies  in  this  form  has  many  advantages 
over  that  of  applying  them  by  means  of  a  speculum,  because  a 
speculum  examination  of  an  ulcerated  rectum,  repeated  two  or 
three  times  a  week,  is  apt  to  do  more  harm  by  its  mere  intro- 
duction than  the  remedies  will  do  good.  The  utmost  gentle- 
ness must  be  used  in  all  cases,  and  the  greatest  care  is  neces- 
sary to  keep  from  irritating  the  part.  I  have  also  found  it  well 
to  mix  about  the  tenth  of  a  grain  of  morphine  with  the  supposi- 
tory, and  administer  this  at  night  and  morning.  It  certainly 
ministers  to  the  local  rest  of  the  part,  and  it  renders  rest  in  bed 
much  more  endurable  in  persons  of  a  nervous  tendency. 

Certain  good  results  may  be  gained  by  applications  to  the 
ulcerated  spot  by  means  of  enema ta,  and  when  the  disease  is 
situated  high  up,  the  amount  of  fluid  injected  should  be  large. 
Three  pints  of  water  may  be  thrown  into  the  upper  part  of  the 
rectum,  the  sigmoid  flexure,  and  the  lower  part  of  the  colon,  if 
the  proper  means  be  adopted,  without  causing  any  uneasiness 
at  the  time  or  any  subsequent  desire  for  an  evacuation.  Long, 
flexible,  soft-rubber  tubes  may  now  be  obtained  from  any  of  the 
surgical  instrument-makers,  which  are  suitable  for  this  purpose. 


NON-MALIGNANT    ULCERATION.  269 

The  tube  should  be  small  and  the  opening  in  it  just  large  enough 
to  hold  securely  the  smallest  end-piece  of  an  ordinary  David- 
son's syringe.  The  injection  should  be  given  with  the  patient 
on  the  side,  and  given  slowly.  The  drug  from  which  the  best 
results  may  be  expected  when  used  in  this  way  is  the  nitrate  of 
silver,  and  the  solution  should  vary  in  strength  from  twenty  to 
forty  grains  to  three  pints  of  water.  This  plan  of  treatment 
has  recently  been  very  successfully  employed  in  cases  of  dysen- 
teric ulceration.  Dr.  Mackenzie '  reports  five  cases  of  cure  by  it, 
and  in  one  of  them,  where  the  disease  had  lasted  two  years  and 
a  half,  the  cure  followed  a  single  injection. 

The  knife  may  serve  a  good  purpose  under  several  circum- 
stances. Where  the  sore  is  of  small  dimensions  and  well-limited 
in  outline,  even  though  it  be  above  the  external  sphincter,  it  is 
sometimes  of  advantage  to  draw  the  knife  across  the  muscular 
fibres  which  form  its  base,  and  secure  rest  for  it  in  this  way. 
The  operation  is  one  of  delicacy,  but  is  also  one  which  may 
assist  greatly  in  the  cure. 

In  cases  of  more  extensive  diseases  above  the  sphincter  and 
at  its  level,  where  the  latter  by  its  action  causes  constant  pain 
and  suffering  (and  indeed  ulceration  of  the  rectum  is  seldom 
very  painful  unless  the  sphincter  is  involved,  and  in  advanced 
cases,  where  it  has  been  entirely  destroyed,  may  be  almost 
painless),  I  am  in  the  habit  of  freely  dividing  that  muscle  in  the 
median  line  posteriorly  by  a  single  incision  through  all  its 
fibres.  In  this  way  relief  is  given  to  suffering,  more  perfect  rest 
is  obtained  than  is  otherwise  possible,  and  a  way  is  opened  for 
such  further  local  treatment  as  may  be  necessary. 

The  operation  may  be  followed  by  incontinence,  though  it 
is  not  apt  to  be  if  the  incision  is  in  the  median  line,  so  that  the 
nerves  are  not  implicated,  and  if  the  internal  sphincter  be  not 
involved  in  the  incision.  The  operation  is  preferable  to  that  of 
stretching  the  muscle,  simply  because  its  effect  is  more  perma- 
nent ;  and,  indeed,  is  a  substitute  for  colotomy  in  the  same  class 
of  cases.  Of  this  operation  I  shall  say  more  in  the  next  chapter, 
when  speaking  of  the  most  frequent  secondary  effect  of  ulcera- 
tion— stricture. 

The  application  of  strong  nitric  acid   to  a  circumscribed 


'  On  the  Treatment  of  Chronic  Dysentery  by  Voluminous  Enemata  of  Nitrate  of 
Silver.     The  Lancet,  April  22,  29,  1882. 


270  DISEASES    OF    THE    RECTUM    AND    ANUS. 

ulcer  of  the  rectum  is  often  attended  by  the  happiest  results,  as 
seen  in  the  following  case  : 

Case.  Ulceration  of  the  Rectum  cared  by  Nitric  Acid. — 
The  patient  was  a  man,  aged  thirty-one,  with  a  full  syphilitic 
history,  who  for  two  j^ears  had  suffered  from  the  usual  signs  of 
ulceration  of  the  rectum.  He  had  bloody  diarrhoea  in  the  morn- 
ing, passed  a  good  deal  of  mucus,  suffered  constantly  from 
pain  in  the  rectum  and  bowels,  and  had  tried  a  thorough  course 
of  constitutional  treatment  without  benefit.  On  examination 
under  ether,  three  distinct  ulcers  were  found  in  the  lower  four 
inches  of  the  bowel,  and  each  of  these  were  thoroughly  cau- 
terized with  nitric  acid.  The  patient  was  then  put  to  bed  for  a 
month,  and  confined  to  milk  diet.  After  the  first  few  days  there 
was  a  marked  relief  to  all  symptoms,  and  the  diarrhoea  and 
pain  disappeared  entirely.  The  subsequent  treatment  consisted 
in  the  daily  administration  of  a  laxative,  and  of  suppositories 
of  iodoform  (gr.  v.).  At  the  end  of  six  weeks  all  signs  of  the 
disease  had  disappeared. 

In  treating  these  cases  by  local  applications  the  surgeon 
must  be  prepared  to  ring  all  the  changes  between  a  two-grain 
solution  of  nitrate  of  silver  and  fuming  nitric  acid,  or  pure 
carbolic  acid.  They  are  cases  which  require  the  utmost  care, 
both  as  to  the  diagnosis,  in  the  first  place,  and  the  treatment ; 
and  many  of  them  will  end  unhappily  in  spite  of  all  that  can 
be  done.  And  yet,  when  they  present  themselves  in  their 
earlier  stages,  before  irreparable  injury  has  been  done,  they 
are  capable  of  being  cured  by  the  treatment  which  has  been 
outlined. 


CHAPTEK  XL 

NON-MALIGNANT  STKICTURE  OF  THE  RECTUM. 

Strictures  Divided  into  Congenital  and  Acquired. — Table  of  Subdivisions. — Complete 
and  Partial  Congenital  Stricture. — Acquired  Stricture. — Stricture  due  to  Pressure 
from  "Without. — Spasmodic  Stricture. — Non-Veneieal  Strictures. —  Dysenteric 
Stricture. — Simple  Inflammatory  Stricture. — Stricture  due  to  Enlargement  of 
Valves  of  the  Rectum. — Traumatic  Stricture. — Venereal  Stricture. — Divided  into 
Cicatricial  and  Neoplastic. — Cicatricial  Venereal  Stricture. — Neoplastic  Venereal 
Stricture. — Pathological  Anatomy. — Changes  in  Rectal  Wall  above  and  below 
the  Stricture. — Changes  in  Parts  around  the  Stricture. — Symptoms. — Value  of 
Flattened  Passages  as  Symptom.  — Signs  or  Obstruction. — Obstruction  with  Strict- 
ure of  Ccnsid  rable  Calibre. — Diagnosis. — Dangers  to  be  Avoided  in  Examination. 
— Difficulty  when  Disease  is  Situated  high  up  in  the  Bowel. — Use  of  Bougie  for 
Diagnosis. — Treatment. — Advisability  of  Anti-Syphilitic  Medication. — Palliative 
Treatment. — Medicinal  Treatment  of  Threatened  Obstruction. — Surgical  Meas- 
ures.— Dilatation,  Gradual  or  Sudden. — Rules  for  Gradual  Dilatation. — Divulsion, 
Dangers  of,  and  Methods  of  Performing. — Treatment  by  Free  Division.  — Descrip- 
tion of  Operation. — Collection  of  Cases. — Results  of  this  Treatment. — Comparison 
with  Colotomy. — Cases  from  Author's  Practice. — Knife  for  Operation. — Excision 
of  Non-Malignant  Stricture. — Colotomy. — Restrictions  to  the  Operation. — General 
Considerations  Regarding  it. — Treatment  of  Stricture  High  Up. 

For  convenience  of  reference  the  following  table  of  the  differ- 
ent varieties  of  stricture  of  the  rectum  has  been  prepared. 


Congenital. 


Acquired . 


STRICTURE   OF  THE  RECTUM. 

1.  Complete. 

2.  Partial. 

1.  Pressure  from  without. 

2.  Spasm. 

fa.  Dysenteric. 

3.  Non-venereal.  -[  b.   Inflammatory. 

^  c.  Traumatic. 
'a 


4.  Venereal. 


5.  Cancer. 


Cicatricial.  (From  Chan- 
croid. From  Secondary 
and  Tertiary  Ulceration.) 

Neoplastic.  (Gummata. 
Ano  -  Rectal  Syphiloma. 
Inflammatory.) 


272  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Congenital  Strictures. — The  congenital  narrowing  of  the  rec- 
tum, both  complete  and  partial,  which  is  sometimes  seen,  has 
been  already  described  in  speaking  of  the  malformations  of 
this  part,  p.  37. 

Acquired  Strictures.  1.  Stricture  due  to  Pressure  from 
without. — A  stricture  of  the  rectum  may  be  due  either  to  a 
change  in  the  wall  of  the  bowel  or  to  pressure  from  without.  A 
tumor  of  any  kind  in  the  pelvis  will  not  infrequently  press  upon 
the  rectum  so  as  to  obstruct  its  calibre.  An  abscess  in  the 
ischio-rectal  fossa  may  be  accompanied  by  an  amount  of  in- 
flammatory deposit  around  the  rectum  sufficient  to  obstruct  it, 
and  a  pelvic  inflammation  in  women  may  be  accompanied  by 
an  exudation  which  in  the  form  of  bands  across  the  bowel  shall 
partially  close  it,  and  at  the  same  time  lead  to  compensatory 
muscular  hypertrophy  of  the  rectal  wall.  Medical  literature  is 
full  of  cases  of  this  nature,  and  here  it  is  only  necessary  to  refer 
to  them  as  a  not  infrequent  cause  of  obstruction  both  of  the 
rectum  and  of  other  parts  of  the  canal. 

2.  Spasmodic  Stricture. — Much  has  been  written  in  times 
past  upon  the  question  of  spasmodic  stricture  of  the  rectum, 
but  at  present  the  condition  is  looked  upon  by  the  best  author- 
ities with  great  doubt,  if  not  with,  absolute  unbelief.  Spas- 
modic contraction  or  stricture  of  the  external  sphincter  is  not 
an  unusual  condition,  and  cases  of  it  from  my  own  practice  and 
that  of  others  will  be  reported  further  on,  but  spasmodic  strict- 
ure of  the  canal  above  this  point  has  always  been  a  matter  of 
belief  and  assertion  rather  than  of  demonstration. 

Allingham  upholds  its  existence,  in  connection  with  organic 
stricture,  as  a  complication  of  the  latter,  and  gives  the  follow- 
ing case  as  proof.  He  says  :  "  There  are,  no  doubt,  many  cases 
of  stricture  in  which  there  is  very  little  deposit  and  much 
spasm,  and  there  are,  on  the  other  hand,  cases  where  much  ob- 
struction exists,  but  very  little  spasm.  A  patient  under  my 
care  at  St.  Mark's  had  a  stricture  so  tight  that  I  could  not  make 
the  point  of  my  little  finger  enter  it ;  on  putting  her  under  the 
full  influence  of  chloroform,  I  could  get  two  fingers  through 
without  difficulty." 

This  case,  if  it  be  admitted,  as  it  generally  will  be  on  so  good 
authority,  actually  proves  more  than  lias  ever  been  proved  be- 
fore with  regard  to  this  question,  and  is  about  the  only  one 
which  really  proves  anything.     I  have  already  referred  to  the 


NON-MALIGNANT    STRICTURE    OF   THE    RECTUM.  273 

difficulty  which  often  exists  in  passing  a  rectal  bougie  from  the 
natural  conformation  of  the  parts.  It  is  upon  this  difficulty 
that  nearly  all  the  arguments  for,  and  the  supposed  cases  of, 
spasmodic  stricture  rest.  When  the  bougie  cannot  be  passed, 
a  spasmodic  stricture  is  supposed  to  be  the  cause.  When,  af- 
ter numerous  trials,  by  a  lucky  manipulation  an  entrance  is 
effected,  the  spasm  has  been  overcome.  To  this  may  be  re- 
duced nearly  all  the  reported  cases  of  this  affection  which  from 
time  to  time  have  appeared  in  the  writings  of  those  who  have 
devoted  attention  to  the  subject. 

Molliere,1  with  his  usual  happy  style,  has  gone  very  nearly 
to  the  bottom  of  this  question.  He  says  that  at  a  not  very  re- 
mote period  there  flourished  by  the  side  of  Ashton,  Curling, 
and  the  surgeons  of  St.  Mark's  Hospital,  certain  specialists  as 
expert  in  finding  strictures  in  the  rectum  as  are  our  laryngolo- 
gists  in  discovering  polypi  in  the  larynx.  These  estimable 
practitioners  gave  themselves  up  to  the  daily  exercise  of  dilata- 
tion by  bougies,  and  to  facilitate  the  practice  one  of  them  had 
invented  a  pair  of  pants  of  a  special  pattern,  dressed  in  which 
novel  livery  his  patients  came  daily  to  have  a  sound  introduced 
into  the  anus. 

This  whole  question  of  spasmodic  stricture  has  been  very 
ably  discussed  by  Van  Buren,2  and  if  the  reader  wishes  to  fol- 
low it  further,  he  can  scarcely  do  better  than  to  consult  that 
article.  Uncomplicated  spasmodic  stricture  of  the  rectum  is  a 
thing  whose  existence  is  not  admitted  by  the  best  authorities, 
and  which  will  seldom  be  found  by  a  skilful  examiner.  It  is, 
perhaps  too  much  to  say  that  it  never  exists  ;  but  a  well-marked 
case  of  it  within  easy  reach  of  the  finger,  which  could  be  plainly 
detected  by  an  ordinary  examination,  and  which  disappeared 
under  chloroform,  is  what  those  who  do  not  believe  in  its  exist- 
ence are  calmly  waiting  to  see. 

Non  -  Venereal  Strictures. — a.  Dysenteric.  Dysenteric  strict- 
ure and  ulceration  have  also  been  already  described.  Stricture 
due  to  this  cause  is,  perhaps,  more  often  multiple  than  when 
due  to  any  other. 

b.  Inflammatory.     Proctitis,  whether  acute  or  chronic,  when 


1  Loc.  cit.,  p.  320. 

2  On  Phantom  Stricture   and  Other  Obscure  Forms   of  Rectal  Disease.      Amer- 
ican Journal  of  the  Medical  Sciences,  October.  1 879. 

18 


274 


DISEASES    OF   THE    RECTUM    AND    ANUS. 


attended  by  sufficient  changes  in  the  structure  of  the  coats  of 
the  rectum  may  result  in  stricture. 

There  is  another  form  of  stricture  which  may  be  considered 
as  on  the  dividing-line  between  the  congenital  and  the  inflam- 
matory, and  which  consists  in  an  enlargement  and  thickening 
of  the  folds  of  mucous  membrane  which  are  normally  present 
in  every  one. 

Quain,1  under  the  head  of  impaction  of  faeces,  describes  the 
case  of  a  man,  aged  forty  years,  who  died  with  a  large  accumu- 
lation which  was  evidently  due  to  the  presence  of  two  crescent- 


FiG.  78. — Longitudinal  Section  of  Stricture  of  the  Rectum  at  the  Plica  Recti  Inferior. 
(Kohlrausch.)  a,  mucous  membrane;  b,  circular  muscular  layer  entering  into  the  fold  of 
the  stricture  ;  c,  cellular  tissue ;  d,  longitudinal  muscular  layer  passing  over  the  stricture. 

shaped  shelves  of  mucous  membrane  projecting  into  the  rectum, 
one  attached  opposite  the  prostate  and  the  other  about  four 
inches  higher.  Each  of  these  was  more  than  an  inch  in  breadth, 
and  into  each  the  circular  muscular  fibres  fully  entered,  while 
even  the  longitudinal  layer  dipped  slightly  inward  at  their  bases. 
Kohlrausch  also  describes  an  analogous  case,  in  which  he  made 
an  autopsy  on  a  criminal  who  had  been  executed.  (Fig.  78.) 
He  found  an  enormous  dilatation  of  the  rectum  above  the  spot 
at  which  he  locates  the  plica  transversalis.     At  that  point  he 


1  Diseases  of  the  Rectum,  p.  273.     London,  1854. 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  275 

discovered  an  undoubted  stricture  which,  from  its  hardness  and 
extent,  he  at  first  considered  cancerous.  It  presented,  however, 
nearly  the  same  anatomical  condition  as  the  one  just  described  ; 
the  mucous  membrane  was  sound  and  formed  a  considerable 
duplicative,  the  circular  muscular  fibre  entered  into  this  dupli- 
cature  and  formed  a  hard,  hypertrophied,  muscular  ring  several 
lines  in  thickness.  The  longitudinal  fibres  passed  directly  over 
the  affected  spot  in  this  case,  however,  and  were  not  unusually 
thick  or  firm,  and  the  space  left  between  the  outer  and  inner 
muscular  layers  by  the  bending  inward  of  the  latter  was  filled 
with  connective  tissue.  A  stricture  was  in  this  way  formed 
without  degeneration  of  the  mucous  membrane — a  condition, 
however,  which  led  to  no  less  serious  results.  Such  a  state 
furnishes  in  itself  the  ground  for  constant  aggravation,  for  the 
longitudinal  fibres  passing  entirely  over  the  fold  must,  by  each 
contraction  and  by  the  necessary  increase  in  their  normal  func- 
tion, augment  the  substance  of  the  fold  more  and  more,  and 
thus  decrease  the  lumen  of  the  gut.  Nelaton,  indeed,  has  writ- 
ten that  valvular  retractions  of  the  rectum  are  most  often  only 
an  hypertrophy  of  his  superior  sphincter,  and  that  the  projec- 
tion formed  by  it  into  the  cavity  of  the  intestine  is  the  point  at 
which  foreign  bodies  are  most  frequently  arrested,  as  well  as 
that  at  which  invaginations  in  young  children  generally  begin, 
and  in  all  these  points  he  is  borne  out  by  Velpeau.1  Sappey a 
says  "  at  the  level  of  this  band  most  of  the  organic  contractions 
of  the  rectum  are  situated  ;  its  study,  therefore,  offers  no  less 
interest  in  a  pathological  than  in  a  physiological  stand-point." 
This  idea  of  the  pathological  relations  of  the  mucous  folds  and 
muscular  bands  in  the  causation  of  organic  strictures  may  be 
traced  through  the  works  of  Arnold,  Tanchou,  Hyrtl,  and 
Houston,  and  has  its  foundation  in  the  fact  that,  as  these  folds 
are  the  most  subject  to  injuries,  so  they  may  be  the  most  fre- 
quent starting-point  of  those  contractions  of  the  rectum  which 
are  due  to  injuries,  especially  those  from  foreign  bodies  intro- 
duced per  anum  or  swallowed,  and  from  masses  of  hardened 
freces,  intestinal  concretions,  etc. 

c.  Traumatic.  A  simple  traumatism  may  result  in  stricture, 
either  by  causing  ulceration  and  cicatrization  or  by  exciting 
a   chronic   inflammation  in   the  submucous   connective   tissue. 

'Velpeau,  Anat.  Chir.,  3d  ed  ,  p.  39.     1837.  2Anat.  Descript.,  t.  iv.,  p.  222. 


276  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Amongst  these  traumatisms  may  be  enumerated  operations 
upon  haemorrhoids,  applications  of  strong  acids,  the  perform- 
ance of  some  surgical  operations,  foreign  bodies,  kicks  and 
falls,  and  the  injury  produced  by  the  head  of  the  child  at  birth. 

4.  Venereal  Stricture. — a.  Cicatricial. — In  the  chapter  on 
ulceration  stricture  has  been  frequently  referred  to  as  a  not  in- 
frequent consequence  of  that  process,  and  the  various  forms  of 
ulceration  which  by  subsequent  cicatrization  were  capable  of 
producing  this  result  have  been  mentioned.  In  a  general  way 
it  may  be  said  that  any  ulcer  which  destroys  even  the  thickness 
of  the  mucous  membrane  to  any  extent  will,  when  healed,  leave 
a  cicatrix,  and  if  such  a  cicatrix  be  at  all  extensive  it  will  by  its 
contraction  cause  subsequent  diminution  in  the  rectal  calibre. 

It  has  been  shown  that  many  of  the  more  severe  forms  of 
rectal  ulceration  are  of  venereal  origin.  The  venereal  sores 
capable  of  producing  a  stricture  are  the  chancroid,  and  the  later 
syphilitic  ulcers.  We  shall  leave  out  of  consideration  the  true 
chancre,  and  the  mucous  patch,  for  the  reason  that  their  influ- 
ence in  the  causation  of  stricture  is  still  rather  a  matter  of  sur- 
mise than  of  proof,  and  the  same  thing  may  be  said  regarding 
gonorrhoea  of  the  rectum. 

For  a  description  of  these  ulcerative  venereal  processes  the 
reader  may  again  refer  to  the  chapter  on  ulceration. 

b.  Neoplastic. — There  is  a  class  of  venereal  strictures  which 
are  not  primarily  ulcerative  and,  therefore,  not  cicatricial ;  these 
we  have  denominated  neoplastic.  In  this  class  are  to  be  placed 
the  gummata  ;  the  ano-rectal  syphiloma,  which  differs  from 
gummy  deposit  rather  clinically  than  microscopically,  both  of 
which  have  already  been  described  ;  and  a  third  late  manifesta- 
tion of  constitutional  syphilis,  which  is  an  inflammation  of  the 
rectal  wall.  This  inflammatory  change  may  involve  a  large 
portion  of  the  rectum.  It  begins  in  the  muscular  fibre,  the  in- 
terstitial tissue  of  which  becomes  filled  with  round  cells  which 
ultimately  form  a  connective  tissue,  and  this  connective  tissue 
by  its  hardening  and  consolidation  finally  causes  the  complete 
destruction  of  the  muscular  element.  This  is  not  to  be  con- 
founded with  the  ano-rectal  syphiloma  in  which  there  is  an 
actual  deposit  of  large  masses  of  new  material  in  the  rectal  wall 
—masses  which  it  may  be  very  difficult  to  distinguish  from 
cancer. 

In  these  various  ways  venereal  disease,  and  especially  syphilis, 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  277 

may  result  in  rectal  stricture,  and  this  accounts  for  the  fact 
that  in  about  fifty  per  cent,  of  all  cases  of  stricture  there  is  a 
syphilitic  history. 

Pathological  Anatomy. — In  studying  the  pathological  an- 
atomy of  stricture,  there  are  several  points  to  be  observed,  for 
changes  will  be  found  not  only  at  the  stricture  itself,  but  both 
above  and  below  it,  and  in  the  surrounding  parts. 

From  what  has  been  said  already,  it  will  be  inferred  that  a 
stricture  which  is  not  the  direct  result  of  a  deposit  of  new 
material  in  the  rectal  wall  will  be  composed  either  of  cicatricial 
tissue,  such  as  is  found  in  other  parts  of  the  body,  or  else  of 
connective  tissue  which  is  firm  and  dense,  and  creaks  under  the 
knife  on  section.  All  the  connective  tissue  in  the  rectum  at  the 
diseased  point,  whether  submucous,  subperitoneal,  or  intermus- 


Fig.  79. — Stricture  of  the  Rectum  showing  Hypertrophy  of  the  Connective  Tissue.     (Bushe. ) 

cular,  will  be  found  to  have  increased  in  quantity,  and  this  ac- 
counts for  the  increased  thickness  of  the  rectal  wall.  (Fig.  79.) 
The  mucous  membrane  at  the  seat  of  stricture  will  generally  be 
found  destroyed,  and  replaced  by  granulation  tissue  on  this 
fibrous  base,  which  bleeds  easily  when  scraped. 

Above  the  constriction  a  process  occurs  which  will  be  found 
to  be  almost  constant.  This  begins  by  a  dilatation  of  the  bowel 
and  an  hypertrophy  of  the  muscular  layer,  with,  at  first,  a 
thickening  of  the  mucous  membrane.  Later,  the  mucous  mem- 
brane, due,  probably,  to  the  irritation  of  retained  faeces,  will 
show  all  the  stages  of  ulceration,  from  simple  congestion  in 
some  points  to  a  complete  destruction  in  others,  and  an  expos- 
ure of  the  muscular  tissue  beneath.  This  ulcerative  process 
may  extend  for  several  inches  up  the  bowel.     The  wall  of  the 


•278  DISEASES    OF    THE    RECTUM    AND    ANUS. 

bowel  above  the  stricture  may  be  as  thin  as  paper  in  spots,  and 
at  such  points  perforation  is  apt  to  take  place.  In  a  case  re- 
ported by  Goodhart,1  the  changes  of  which  we  are  speaking  had 
gone  on  to  actual  gangrene,  extending  in  spots  along  the  trans- 
verse and  descending  colon,  and  were  undoubtedly  due  to  the 
intensity  of  the  inflammatory  action  caused  by  the  retained  ir- 
ritant matters.  The  bowel  is  also  generally  distended  with  gas 
and  faeces,  and  the  latter  are  more  often  fluid  than  solid,  though 
faecal  tumors,  with  their  well-known  characteristics,  will  some- 
times be  met. 

The  dilatation  above  the  stricture  may  reach  an  enormous 
size,  and  may  ultimately  result  in  a  cul-de-sac  or  pouch  which 
will  All  a  large  portion  of  the  abdomen,  and  dip  down  below  the 
point  of  constriction,  and  an  ulceration  in  this  pouch  may  re- 
sult in  its  perforation  and  the  establishment  of  a  fistulous  out- 
let for  the  faeces.  Such  an  opening  may  be  into  the  rectum, 
either  above  or  below  the  stricture,  or  into  the  ischio-rectal 
fossa,  with  the  necessary  result  of  abscess.  An  opening  may 
also  be  made  into  the  bladder  in  either  sex,  and  in  females,  into 
any  part  of  the  genital  tract. 

As  showing  what  efforts  nature  is  capable  of  making  to 
overcome  the  occlusion  caused  by  stricture,  the  following  ac- 
count of  the  post-mortem  appearances  found  in  the  body  of 
Talma,  the  tragedian,  is  of  great  interest.  The  whole  history 
of  the  case  may  be  found  in  Quain.2 

In  the  examination  of  the  body  the  intestines  were  all  found 
largely  distended  with  air  and  faecal  matter.  .  .  .  The 
pelvis  was  filled  with  an  enormous  sac— the  upper  part  of  the 
rectum  largely  dilated.  When  the  sac  was  raised  a  circular 
narrowing  of  the  gut  was  discovered.  This  was  the  stricture. 
It  was  at  the  distance  of  six  inches  from  the  anus,  and  proved, 
upon  close  examination,  to  be  wholly  impervious.  It  was,  in 
fact,  a  solid  fibrous  cord,  but  on  the  surface  irregular,  and  hav- 
ing the  appearance  of  a  purse,  drawn  tightly  and  puckered, 
with  the  strings  tied  around  it.  The  great  dilatation  of  the 
bowel  at  its  lower  end,  dipped  down  below  the  level  of  the 
stricture  in  the  form  of  a  dependent  sac,  in  which  was  an  open- 
ing about  an  inch  in  diameter,  and  from  this  opening  issued  a 
fluid,   the   same  as  that  diffused  through  the  abdomen.     The 


Med.  Times  and  Gaz.,  February  28,  1880.  '  Op.  cit.,  p.  190. 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  279 

rectum  below  the  stricture  was  no  more  than  the  size  of  a  child's 
intestine,  and  upon  it,  close  to  the  stricture,  was  an  ulcerated 
surface  with  a  narrow  opening,  to  which  the  edges  of  the 
aperture  above  the  stricture  had  been  adherent.  A  new  com- 
munication, but  an  imperfect  one,  had  thus  been  established 
between  the  two  parts  of  the  gut — severed  one  from  the  other 
by  the  stricture.  But  the  connection  had  given  way,  doubtless 
in  consequence  of  the  violence  of  the  expulsive  efforts,  and  thus 
the  contents  of  the  bowel  had  escaped  a  short  time  before  death. 

The  cellular  tissue  in  the  ischio-rectal  fossae  around  a  stric- 
ture may  also  become  hard  and  lardaceous,  as  a  result  of  chronic 
inflammation  ;  and  this  change  may  extend  to  some  distance 
from  the  original  starting-point  along  the  sacrum,  as  high  as  the 
promontory,  and  into  the  subperitoneal  tissue  of  the  iliac  fossae. 

Abscess  is  always  liable  to  occur  in  the  neighborhood  of  the 
stricture,  probably  from  lowered  vitality  in  the  parts,  and  this 
accounts  for  the  relative  frequency  of  fistulse  in  this  disease. 
These  may  be  both  numerous  and  extensive,  and  may  make 
communications  between  the  rectum  and  any  of  the  adjacent 
organs.  For  this  reason  a  fistula  should  always  lead  the  surgeon 
to  think  of  stricture  and  to  examine  for  it. 

Allingham  has  also  called  attention  to  the  frequent  existence 
of  a  low  form  of  peritonitis  in  connection  with  stricture,  an  in- 
flammation marked  by  tympanites,  vomiting,  and  pain,  espe- 
cially on  walking  or  moving,  and  attended  by  thickening  of 
the  peritoneum  and  old  and  recent  adhesions. 

Below  the  stricture  the  rectum  may  sometimes  be  found 
unchanged  from  its  normal  condition,  but  it  will  generally  be 
ulcerated  as  it  is  above,  or  else  there  will  be  hsemorrhoidal 
tumors,  excoriations,  and  vegetations  and  condylomatous  tags 
of  larger  or  smaller  size.  These  cond}domatous  growths  are  the 
result  simply  of  irritation  of  the  discharge  from  the  process  above. 

Most  strictures  are  located  in  the  lower  part  of  the  rectum, 
and  hence  their  presence  is  easily  detected  in  the  majority  of 
cases.  They  are  far  more  frequent  in  females  than  in  males, 
because  many  of  the  causes  which  produce  them  operate  chiefly 
in  females.  Age  has  little  influence  upon  their  frequency  after 
the  period  of  adult  life.  A  stricture  may  or  may  not  involve 
the  whole  circumference  of  the  bowel  ;  and  the  contraction 
may  be  so  slight  as  not  to  be  apparent  till  the  bowel  is  dis- 
tended with  the  speculum,  when  a  falciform  band  may  spring 


2S0  DISEASES    OF    THE    RECTUM    ATJD    A1NTCS. 

out  from  one  side.  In  more  extensive  disease,  there  is  still 
usually  a  passage  for  the  faeces,  but  this  may  be  very  slight. 
The  most  extensive  disease  will  be  found  to  be  due  generally 
either  to  syphilitic  deposit,  syphilitic  sclerosis,  or  dysentery  ; 
and  in  such  cases  the  calibre  of  the  bowel  may  be  lessened  for 
a  space  of  several  inches. 

Symptoms. — Where  stricture  is  the  result  of  ulceration,  the 
signs  of  ulceration  will  at  first  mask  those  of  the  stricture,  and 
the  patient  will  complain  of  pain,  discharge  from  the  anus, 
excoriations,  and  warty  growths,  together  with  the  failure  of 
the  general  health,  gastric  and  intestinal  disturbance,  and  wan- 
dering pains. 

The  one  sign  of  a  stricture  is  the  obstruction,  and  this  may 
show  itself  in  several  ways,  generally  at  first  by  alternate  at- 
tacks of  constipation  and  diarrhoea.  The  constipation  is  me- 
chanical, and  is  due  to  the  accumulation  of  faeces  above  the 
constriction.  The  diarrhoea  is  secondary  to  the  accumulation, 
which,  in  time,  begins  to  act  as  a  foreign  body,  setting  up  a 
catarrhal  inflammation,  as  a  result  of  which  sufficient  fluid  is 
poured  into  the  bowel  to  soften  the  hardened  mass,  and  large 
quantities  are  discharged,  only  to  be  followed  by  a  fresh  ac- 
cumulation. 

It  has  often  been  asserted  that  a  well-marked  lessening  of  the 
rectal  calibre  must,  in  the  nature  of  things,  produce  a  change 
in  the  shape  of  the  fasces,  but  this  is  not  quite  true.  The 
flattened,  tape-like  stool  is  a  sign  of  value  when  present,  and 
should  always  lead  to  careful  exploration,  but  it  may  not  be 
present  even  in  the  worst  cases  of  stricture,  and  it  may  exist 
without  stricture  ;  in  the  latter  case  generally  being  due  to  an 
irregular  spasmodic  action  of  the  sphincters,  or  to  pressure 
from  without  the  bowel.  This  point,  to  which  attention  was 
called  by  White  '  as  long  ago  as  1815,  has  again  recently  been 


1  "With  regard  to  the  lessened  diameter  of  the  fasces,  just  noticed,  which  must 
necessarily  he  the  case  whenever  a  permanently  contracted  state  of  the  gut  takes 
place  ;  yet  it  has  happened  in  some  instances  where  that  change  had  been  observed, 
that,  in  a  more  advanced  period  of  the  disease,  freces  of  a  natural  size  had  occasionally 
passed.  The  knowledge  of  this  circumstance  I  consider  of  some  importance, 
inasmuch  as.  if  properly  attended  to,  it  will  prevent  the  practitioner  from  hastily 
concluding  there  is  no  stricture  merely  from  an  examination  of  the  evacuations,  when 
symptoms  may  otherwise  indicate  the  presence  of  the  disease." — Observations  on 
Stricture  and  other  Affections  occasioning  a  Contraction  in  the  Lower  Part  of  the 
Intestinal  Canal,  etc.     Bath,  1*1'). 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  281 

made  the  subject  of  discussion.  In  an  able  article  on  "  Annu- 
lar Stricture  of  the  Intestine  ;  its  Diagnosis  and  Treatment,"  in 
the  Britisli  Medical  Journal  for  Maj^  31,  1879,  Mr.  Stephen 
Mackenzie  wrote :  "  The  fact  that  full-sized,  properly  formed 
faeces  are  occasionally  passed,  of  course  shows  that  there  can 
be  no  organic  stricture."  Under  criticism,  he  withdrew  the 
statement  in  the  issue  of  the  same  journal  for  May  15,  1880, 
with  the  explanation  that  it  was  founded  on  his  personal  ob- 
servation, which  had  since  been  supplemented  and  corrected  by 
that  of  others. 

In  a  case  which  I  once  saw  in  consultation  with  Dr.  De  Long, 
of  Brooklyn,  I  had  a  long-wished-for  opportunity  to  observe,  in 
the  presence  of  a  number  of  physicians,  the  actual  mechanism 
by  which  tape-like  stools  are  produced.  The  woman  suffered 
from  a  stricture  one  inch  above  the  anus,  which  was  of  suffi- 
cient calibre  to  admit  the  ends  of  two  fingers  easily.  She  had 
never  noticed  any  deformity  of  the  faeces.  While  under  the  in- 
fluence of  ether,  and  after  the  sphincter  had  been  very  thor- 
oughly dilated,  an  O'Beirne  tube  was  passed  through  the  rec- 
tum, which  was  empty,  into  the  sigmoid  flexure,  which  was  full. 
After  resting  there  a  few  moments,  it  provoked  a  movement  of 
the  bowels.  The  stricture  was  instantly  crowded  down  into 
view,  appearing  at  the  anus,  and  taking  the  place  of  the  anus, 
which,  owing  to  the  complete  dilatation,  ceased  to  have  any 
action,  and  was  simply  a  patulous  ring.  Through  the  stricture 
there  came  a  long,  tape-like  evacuation,  the  mould  which  gave  it 
its  peculiar  form  being  the  stricture  pressed  to  the  surface  of 
the  perinseum,  and  greatly  lessened  in  calibre  by  folds  of  mu- 
cous membrane,  which  were  crowded  into  it  from  above.  While 
remarking  to  those  present  on  the  peculiar  mechanism  of  its 
production,  the  straining  ceased,  the  stricture  rose,  the  mucous 
membrane  was  relaxed,  and  a  passage  of  natural  formation  was 
the  result.  This  alternation  was  repeated  several  times.  At 
each  violent  effort  the  stricture  was  forced  down  to  the  anus, 
the  membrane  above  it  was  crowded  into  it  so  as  to  greatly  les- 
sen its  calibre,  and  a  flat  passage  was  the  result.  When  the 
effort  was  less  violent,  there  was  still  a  passage,  but  the  stric- 
ture having  risen  to  its  place,  and  not  being  so  tightly  filled 
with  the  mucous  membrane,  the  passage  was  natural.  The  les- 
son to  my  own  mind  was  this  :  that  a  stricture  of  large  calibre 
might,  as  a  result  of  straining,  cause  a  passage  of  very  small 


2S2  DISEASES    OF    THE    RECTUM    AND    ANUS. 

size  ;  and  that,  to  get  this  peculiar  shape,  the  stricture  must  be 
crowded  down  so  as  to  actually  take  the  place  of  the  external 
sphincter,  and  be  the  last  contracted  orifice  through  which  the 
soft  substance  is  expressed.  It  is  well  known  that,  with  the 
closest  stricture  high  up,  the  faeces  may  be  reformed  in  the  rec- 
tum below,  and  be  passed  normal  in  size.  At  the  bedside  but 
little  importance  is  to  be  attached  to  the  statements  of  patients 
concerning  this  matter. 

After  a  stricture  has  existed  for  a  certain  length  of  time, 
signs  of  obstruction  will  be  manifest  by  abdominal  palpation 
and  inspection.  The  transverse  and  descending  colon  can  be 
felt  partially  distended  with  masses  of  faeces,  and  will  be  dull  on 
percussion,  tender  to  the  touch,  somewhat  movable,  and  pitting 
on  firm  pressure.  After  an  attack  of  diarrhoea,  or  after  a  brisk 
purge,  these  accumulations  may  disappear,  only  to  form  again 
in  a  short  time.  Generally  complete  obstruction  does  not  occur 
without  ample  warning  in  this  way.  It  is  preceded  by  eructa- 
tions of  fetid  gas,  the  abdomen  swells  and  becomes  very  tender 
on  pressure,  the  coils  of  intestine  are  visible  through  the  ab- 
dominal wall,  and  their  visibly  violent  peristalsis  gives  proof  of 
the  effort  nature  is  making  to  overcome  the  obstacle.  After  a 
short  time  the  patient  is  exhausted,  and,  unless  surgical  aid  is 
given,  dies.  Complete  obstruction  has  been  seen  to  occur  very 
suddenly,  forming  almost  the  first  intimation  of  serious  disease; 
and  this  is  more  apt  to  be  the  case  where  the  stricture  is  high 
up  in  the  rectum  or  at  the  junction  with  the  sigmoid  flexure. 
It  comes  on  with  the  usual  signs  of  acute  intestinal  strangula- 
tion— pain,  swelling  of  the  abdomen,  bloody  passages,  etc.,  and 
it  may  be  caused  by  some  indigestible  substance  which  has  been 
swallowed  and  refuses  to  pass  the  stricture,  or  merely  by  hard- 
ened faeces  or  prolapse  of  the  bowel  above  into  the  constriction. 
The  following  case  is  one  of  quite  a  large  class  : 

"The  patient,  a  middle-aged  woman,  was  admitted  into  St. 
Bartholomew's  Hospital  with  symptoms  of  sudden  obstruction. 
She  stated  that  she  had  enjoyed  good  health  up  to  the  onset  of 
the  attack,  nor  had  she  previously  been  troubled  with  consti- 
pation. The  attack  commenced  suddenly  while  at  work,  and 
was  followed  by  obstinate  vomiting  and  constipation.  The 
symptoms  having  existed  for  some  days,  and  the  case  appear- 
ing urgent,  while  the  sudden  onset  of  the  symptoms  suggested 
mechanical  strangulation,  it  was  deemed  advisable  to  open  the 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  283 

abdominal  cavity.  This  being  done,  Mr.  Marsh  felt  a  hard 
cancerous  mass  in  the  walls  of  the  bowel,  which  caused  the 
obstruction.  The  bowel  was  opened  above  the  obstruction  and 
stitched  to  the  sides  of  the  wound,  the  patient  making  a  good 
recovery."  ' 

There  is  one  important  element  in  the  obstruction  due  to 
stricture  which  must  not  be  forgotten.  It  will  sometimes  hap- 
pen that  fatal  obstruction  will  occur  even  when,  on  post-mortem 
examination,  the  calibre  of  the  stricture  is  found  to  be  large 
enough  to  permit  the  passage  of  the  finger,  showing  that  the 
obstruction  could  not  have  been  due  merely  to  the  contraction 
of  the  new  growth.  John  Hunter  remarked  a  fact  of  this  sort, 
as  is  proved  by  the  following  account : 

"  On  introducing  the  pipe  by  the  anus,  it  was  found  to  come 
butt  against  one  side  of  the  upper  part  of  the  cavity  of  the 
tumor,  where  there  was  a  bend  in  the  passage  ;  but  why  a 
crooked  pipe  did  not  pass  when  attempted  to  be  passed  by 
turning  it  to  all  sides,  I  cannot  conceive,  or  why  a  bougie 
which  was  slightly  bent  did  not  hit  the  hole,  is  not  easily  ac- 
counted for ;  but,  what  is  more  extraordinary  than  either,  why 
a  clyster  did  not  pass  freely  up  ;  or  why  did  not  the  wind  or 
soft  excrementitious  matter  that  did  yet  lay  [sic]  pass  readily 
down,  while  I  could  pretty  readily  pass  the  end  of  my  finger 
down  from  the  gut  above  into  the  tumor?  The  folds  of  the 
contracted  part  did  not  appear  after  death  to  have  been  suffi- 
cient for  an  entire  stoppage  of  this  sort."  2 

Notwithstanding  the  statement  that  the  folds  of  the  part 
did  not  appear  after  death  to  have  been  sufficient  to  produce 
the  stoppage,  it  seems  that  a  prolapsed  fold  of  mucous  mem- 
brane is  the  only  thing  likely  to  give  rise  to  it.  In  cases  of  ad- 
vanced disease  a  spasmodic  stricture  (if  such  ever  occurs)  would 
seem  out  of  the  question,  whereas  partial  or  complete  invagina- 
tion in  this  part  is  known  to  be  of  frequent  occurrence.  As 
shown  by  Rokitansky,"  the  paralysis  above  the  stricture  is  also 
an  undoubted  element  in  the  production  of  the  occlusion. 

Diagnosis. — The  first  means  of  diagnosis  in  stricture  is  the 
examination  with  the  finger,  and  as  the  great  majority  of  stric- 

1  Cripps :  Cancer  of  the  Rectum,  p.  107. 

sHunterian  MS.     Cases  and  Dissections,  No.  59,  in  Descriptive  Catalogue,  etc., 
vol.  iii.,  p.  98.     From  Mayo,  op.  cit.,  p.  249. 

!  Manual  of  Path.  Anat.,  vol.  ii.,  translated  by  Sieveking. 


284  DISEASES    OF    THE    RECTUM    AND    ANUS. 

tures  are  confined  to  the  lower  portion  of  the  rectum  this  is  in 
itself  generally  sufficient.  It  is  the  best  and  safest  and  least 
painful  of  all  the  means  of  diagnosis  when  properly  executed, 
and  yet  it  may  be  the  immediate  cause  of  death  to  the  patient 
when  roughly  practised.  There  is  an  inborn  tendency  on  the 
part  of  many,  when  the  index  finger  comes  in  contact  with  a 
tight  stricture,  to  bore  through  the  narrow  passage  which  is 
left  and  feci  what  is  on  the  other  side — a  tendency  to  be  strug- 
gled against  and  overcome.  If  the  surgeon  has  deliberately  de- 
termined to  practise  divulsion,  this  is  one  way  to  do  it,  but  at 
present  we  are  speaking  of  diagnosis,  and  forcible  dilatation  is 
not  diagnosis,  but  a  very  grave  surgical  procedure.  The  finger 
should  therefore  be  passed  slowly  up  to  the  stricture,  and  unless 
the  calibre  admits  of  it  without  straining,  it  should  not  be 
passed  further.  The  condition  of  the  parts  below  may  also  be 
appreciated,  the  amount  of  induration  estimated,  and  a  general 
idea  formed  of  the  nature  and  extent  of  the  disease.  In  women 
the  vaginal  touch  will  generally  be  found  of  the  greatest  value 
and  should  never  be  omitted. 

As  a  rnle  all  can  be  learned  in  this  way  that  can  be  learned 
in  any  other  where  the  disease  is  within  reach  of  the  finger,  and 
nothing  is  to  be  gained  by  a  painful  speculum  examination  or 
the  use  of  the  bougie — means  of  diagnosis  which,  however  valu- 
able where  the  stricture  cannot  be  felt  by  the  finger,  are  of  little 
use  for  the  lower  four  inches  of  the  rectum. 

When  a  stricture  is  situated  high  up  in  the  rectum  or  in  the 
sigmoid  flexure,  the  confidence  in  diagnosis  which  comes  from 
actual  contact  of  the  finger  with  the  disease  is  entirely  lost,  and 
there  is  perhaps  nothing  in  the  whole  range  of  surgical  diagnosis 
which  requires  more  skill  than  the  detection  of  stricture  in  this 
part,  and  nothing  attended  with  more  uncertainty.  The  symp- 
toms of  stricture  of  the  upper  part  of  the  rectum  are  not  the 
same  as  when  the  disease  is  lower  down,  for  the  nerve-supply  is 
not  the  same,  nor  is  the  sphincter  muscle  involved.  For  this 
reason  the  patient  is  much  more  apt  to  suppose  himself  suffer- 
ing from  chronic  constipation  and  dyspepsia  than  from  hemor- 
rhoids. Pain  in  the  abdomen,  not  always  localized  at  the  left 
side,  pain  in  the  loins  and  down  the  legs,'  obstinate  constipation 
and  occasional  diarrhoea,  are  the  things  usually  complained  of, 
and  in  these  there  is  nothing  upon  which  to  base  a  positive 
diagnosis.     The  faeces  may  never  present  any  peculiarity,  for 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  285 

tlie  reason  that  they  are  accumulated  in  the  rectal  pouch  below 
the  obstruction  and  passed  in  the  natural  shape.  They  are  apt 
to  be  lumpy  and  unformed  rather  than  misformed,  but  they 
may  be  streaked  with  blood  or  slime,  which  is  always  a  valuable 
sign  and  one  calling  for  careful  physical  exploration. 

A  stricture  in  the  locality  in  question  must  be  examined  for 
with  the  greatest  care  and  gentleness,  and  the  examination  will 
often  be  negative  in  its  results.  The  attempt  to  decide  the 
question  by  the  use  of  bougies  is  altogether  unsatisfactory  and 
by  no  means  free  from  danger.  It  is  unsatisfactory  because  an 
obstruction  will  generally  be  encountered  in  trying  to  pass  an 
instrument  of  any  considerable  size  through  this  part  of  the 
bowel,  and  the  passage  of  an  instrument  of  small  size,  which  is 
much  easier,  proves  nothing.  It  is  dangerous  because,  with  the 
ordinary  rubber  rectal  bougies,  a  diseased  bowel  may  easily  be 
ruptured  with  what  may  seem  to  the  operator  to  be  no  more 
force  than  is  justified  in  attempting  to  overcome  the  natural  ob- 
structions to  this  part  of  the  passage.  The  bulbous-pointed 
bougie  on  the  flexible  stem  appears  d  priori  to  be  the  most 
suitable  for  the  exploration,  but  it  has  two  objectionable  fea- 
tures. It  is  not  at  all  an  easy  instrument  to  pass,  and  if  passed 
through  an  obstruction  too  much  force  is  required  for  its  with- 
drawal after  the  abrupt  shoulder  is  in  contact  with  the  stricture. 

O'Beirne  gives  the  following  description  of  the  way  to  pass 
his  tube:  "A  gum  elastic  catheter  of  the  largest  size  was  in- 
serted into  the  anus,  and  passed  to  the  height  of  about  two 
inches  up  the  rectum,  where  its  further  progress  was  felt  to  be 
opposed  by  strong  expulsive  efforts,  which  lasted  but  a  few 
seconds,  then  relaxed,  and  again  became  renewed.  By  first 
yielding  somewhat  to  these  efforts,  and  then  taking  advantage 
of  the  succeeding  relaxation,  the  instrument  was  gradually 
passed  to  the  height  of  seven  or  eight  inches.  At  this  point 
the  resistance  was  sensibly  felt  to  be  much  greater  than  at  any 
former,  but,  instead  of  allowing  it  to  yield,  the  instrument  was 
pressed  more  firmly  upward.  Having  steadily  continued  this 
pressure  for  about  one  minute,  the  resistance  suddenly  gave 
way,  the  tube  passed  upward  as  if  through  a  narrow  ring,"  etc. 

Even  with  the  softest  instrument,  the  moment  when  the  ob- 
struction suddenly  gives  way,  and  the  instrument  passes  for- 
ward, will  be  an  anxious  one  for  the  surgeon,  and  the  life  of 
the  patient  may  be  sacrificed  to  desire  for  certainty  of  diagnosis. 


286  DISEASES    OF   THE    RECTUM    AND    ANUS. 

A  bougie  intended  for  this  purpose  should  always  be  hollow, 
and  the  opening  at  the  lower  end  should  be  of  a  size  to  admit 
the  small  tube  of  a  Davidson  syringe,  which  should  be  fitted 
to  it  before  the  attempt  to  pass  it  is  begun.  Then  with  a  basin 
of  warm  water  close  at  hand  the  bougie  may  be  introduced,  and 
at  the  first  obstruction  the  bowel  should  be  filled  with  water 
until  it  is  moderately  distended.  In  this  way  the  folds  of 
mucous  membrane  are  drawn  out  of  the  way  by  the  distention 
of  the  whole  bowel,  and  one  great  obstacle  is  eliminated.  The 
next  is  the  promontory  of  the  sacrum,  which  is  much  more 
easily  passed  by  a  soft  than  by  a  stiff  instrument.  Without 
these  precautions,  and  sometimes  with  them,  the  inexperienced 
examiner  will  find  a  stricture  in  the  rectum  of  nineteen  persons 
out  of  twenty,  no  matter  how  healthy  they  may  be ;  and  for  this 
reason  it  is  seldom  safe  to  rest  the  diagnosis  of  stricture  on  the 
fact  that  a  bougie  cannot  be  made  to  pass.  Moreover,  a  bougie 
of  good  size  will  often  pass  a  stricture  small  enough  to  produce 
great  trouble. 

In  certain  cases  information  may  be  gained  by  the  use  of  a 
long  cylindrical  speculum  with  the  patient  bending  over  the 
table  or  chair  and  straining  down  to  bring  the  parts  into  view. 
Fortunately,  however,  we  are  not  limited  to  either  of  these 
means  for  a  diagnosis,  for,  if  the  stricture  be  cancerous  and  of 
any  size  the  mass  may  be  felt  through  the  abdominal  wall  by 
careful  palpation  ;  and  if  not,  and  the  symptoms  warrant  it,  the 
sphincter  may  be  stretched  or  incised  sufficiently  to  allow  of 
introducing  the  hand  into  the  rectal  pouch.  Passing  the  whole 
hand  into  the  rectal  pouch,  and  then  the  finger  into  the  sigmoid 
flexure  as  far  as  possible,  is  a  very  different  affair  from  trying 
to  pass  the  whole  hand  into  the  flexure,  and  is  free  from  danger, 
because  the  distention  by  the  hand  is  not  carried  to  the  point 
where  danger  is  located,  at  the  reflection  of  the  peritoneum. 
Though  seemingly  a  much  more  serious  matter,  it  is  really  safer 
than  any  forcible  use  of  the  bougies,  and  by  it  the  diagnosis 
maybe  rendered  certain  for  all  that  part  of  the  bowel  at  present 
under  consideration.  I  know  of  no  other  way  than  this  by 
which  a  stricture  in  the  sigmoid  flexure,  which  cannot  be  felt 
by  external  manipulation,  can  certainly  be  recognized. 

Treatment. — The  treatment  of  stricture  of  the  rectum  is 
both  constitutional  and  local,  medicinal  and  operative.  The 
first  question  to  be  answered  is  as  to  the  advisibility  of  anti- 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  287 

syphilitic  medication.  In  recent  cases  where  syphilis  is  to  be 
suspected  this  should  never  be  omitted. 

It  is  well  to  exercise  caution  in  this  matter,  however,  and 
the  cases  in  which  the  patient  should  be  submitted  to  this  form 
of  treatment  should  be  carefully  chosen.  The  practitioner  who 
considers  the  majority  of  strictures  as  syphilitic,  and  indiscrim- 
inately uses  mercury  and  iodide  of  potash,  will  be  mistaken 
about  as  often  as  he  who  looks  upon  most  of  his  cases  as  can- 
cerous and  therefore  incurable.  The  general  condition  of  a 
patient  with  a  stricture  is  never  up  to  the  normal,  and  an  un- 
necessary course  of  medication  may  do  great  harm. instead  of 
good. 

Cicatricial  tissue,  though  the  result  of  specific  disease,  is  be- 
yond the  reach  of  specific  treatment,  but  where  the  case  can 
be  seen  clearly  enough,  much  improvement  can  be  gained  by  a 
thorough  course  of  mixed  treatment,  and  a  gummatous  deposit 
or  a  syphilitic  sclerosis  may  be  checked.  Mercury  and  iodide 
of  potash  should  both  be  given,  neither  being  relied  upon  alone. 
Mercury  in  the  form  of  an  ointment  or  the  oleate  may  also  be 
administered  by  the  rectum,  and  the  full  constitutional  effects 
of  the  drug  may  be  gained  in  a  very  short  time  by  this  method  ; 
it  is,  however,  an  irritating  application,  and  in  cases  of  much 
ulceration  and  sensitiveness  it  may  not  be  well  borne. 

M.  Trelat  *  has  seen  good  effects  follow  internal  medication 
in  cases  of  ano-rectal  syphiloma,  though  Fournier  speaks  so 
positively  as  to  their  uselessness.  He  gives  two  cases  in  which 
the  disease  was  of  long  standing,  but  yielded  to  a  considerable 
degree  to  the  use  of  mercury  and  iodide  of  potash  internally, 
with  glycerin  applied  locally.  Van  Buren  2  has  also  seen  good 
effects  in  a  case  of  this  kind  from  the  use  of  the  modified  Zitt- 
man's  decoction,  in  mild  doses,  guarded  by  bismuth,  combined 
with  inunctions  of  the  oleate  of  mercury. 

The  following  case  taken  from  Zappula 3  is  worth  reproducing 
entire,  proving  as  it  is  supposed  to  do  that  a  syphilitic  stricture 
which  is  so  extensive  as  to  give  rise  to  the  diagnosis  of  malig- 
nant disease  may  be  made  to  completely  disappear  by  specific 
treatment.     The  author  says :   "  The  patient  who  is  the  subject 

1  Le  Progres  Med.,  June  22,  1878. 

5  On  Phantom  Stricture,  etc.     The  American  Journal  of  the  Medical  Sciences,  Oc- 
tober, 1879. 

3  Annali  universali  de  Medicina,  vol.  cexvii.,  p.  137. 


288  DISEASES    OF    THE    RECTUM    AND    ANUS. 

of  this  case  is  one  of  my  colleagues  and  an  intimate  friend,  a 
man  thirty-six  years  of  age  and  of  nervous  temperament.  The 
family  history  is  good.  The  patient  has  always  enjoyed  good 
health  with  the  exception  of  some  attacks  of  malaria,  a  gonor- 
rhoea contracted  in  1851,  and  some  months  after  an  ulcer  in  the 
balano-preputial  fold,  which  was  followed  by  a  painful  adenitis 
in  the  right  groin  which,  however,  did  not  suppurate.  The 
ulcer  was  of  considerable  size,  lasted  about  forty  days,  and 
ended  by  healing  under  the  influence  of  repeated  cauterizations. 
Nothing  more  is  known  of  the  character  of  that  ulceration,  and 
it  is  impossible  to  establish  any  connection  between  it  and  the 
disease  under  consideration.  But  it  is  certain  that  the  patient 
used  in  inunctions  more  than  one  hundred  grammes  of  mer- 
curial ointment,  and  that  an  examination  of  the  former  site  of 
the  ulcer  shows  now  no  trace  of  its  existence. 

"The  first  symptom  of  the  present  disease  was  pain  which 
started  from  the  right  side  of  the  anus,  extended  as  far  as  the 
tuberosity  of  the  ischium  on  the  corresponding  side,  or  some- 
times took  an  opposite  course,  but  always  was  confined  to  the 
ano-rectal  region.  The  pain  was  of  neuralgic  character,  inter- 
mittent, returning  with  more  or  less  frequency,  but  always  very 
severe  and  accompanied  by  the  phenomena  of  spasm.  Defe- 
cation became  a  little  less  frequent,  but  was  painless  except 
once,  when  there  was  a  sharp  pain  about  the  anus.  A  fissure 
was  suspected,  and  though  it  was  impossible  to  discover  it, 
a  suitable  injection  of  laudanum  and  rhatany  was  administered. 

"The  pain  disappeared  from  the  ischio-rectal  fossae,  but 
symptoms  of  impaction  followed  which  purgatives  in  large  doses 
failed  to  relieve,  and  which  on  the  contrary  led  to  still  more 
alarming  accidents.  It  was  under  these  circumstances  that  I 
first  saw  the  patient,  on  the  24th  of  September.  He  had  suffered 
for  one  month  and  his  condition  seemed  to  be  very  serious. 
Three  large  faecal  tumors  occupied  the  left  iliac  fossa,  the  epi- 
gastrium, and  the  right  flank.  Severe  colic  starting  from  the 
left  iliac  fossa  extended  over  the  whole  abdomen  and  reached 
to  the  anus.  The  abdomen  was  swollen  and  painful  to  the 
touch,  and  pain  was  also  caused  by  pressure  in  the  ano-ischiatic 
region,  where,  however,  no  trace  of  organic  disease  could  be 
discovered.  An  examination  of  the  anus  led  to  the  discovery 
of  a  stricture  so  tight  that  only  the  end  of  the  little  finger  could 
be  introduced  without  causing  great  pain. 


NON-MALIGNANT    STPJCTURE    OF    THE    RECTUM.  289 

"  Such  was  the  group  of  symptoms  the  patient  presented 
when  I  first  examined  him  :  retraction  of  the  anus  and  probably 
of  the  rectum  ;  absolute  necessity  of  causing  the  disappearance 
of  the  obstacle  to  the  exit  of  faeces,  and  of  exciting  intestinal 
contraction.  But  it  was  impossible  for  me  to  know  whether 
the  contracture  was  due  to  ragades  located  immediately  within 
the  anus,  to  the  neuralgic  symptoms  described  above,  or  to 
some  neoplasm  in  the  lower  part  of  the  rectum.  Nevertheless 
I  attacked  the  symptom  of  contracture  by  the  method  of 
Recamier,  and  it  may  be  imagined  how  painful  this  proceeding 
was  while  the  state  of  the  sufferer  did  not  permit  me  to  give 
ether.  However,  during  the  operation  I  discovered  an  enor- 
mous dilatation  of  the  lower  portion  of  the  rectum,  from  which 
escaped  a  considerable  quantity  of  glairy  matter.  Twice  after- 
ward I  administered  large  doses  of  purgatives,  but  the  patient 
vomited  them  almost  immediately,  and  the  abdominal  meteorism 
increased.  Then  the  vomiting  became  spontaneous,  the  fever 
increased,  and  the  symptoms  of  strangulation  became  so  intense 
that  the  life  of  the  patient  seemed  to  me  about  to  be  sacrificed, 
when  again,  under  the  influence  of  two  inunctions  of  croton-oil 
on  the  abdomen,  there  followed  a  tumultuous  expulsion  of 
faeces.  More  than  twenty  hard,  round,  faecal  masses  came 
away,  and  after  this  relief  all  went  well.  But  the  patient's  ease 
only  lasted  a  few  days,  for  the  faeces  very  soon  accumulated 
afresh,  without  forming  tumors,  however ;  the  passages  were 
made  with  difficulty  ;  and  purgatives  administered  from  time 
to  time  caused  the  expulsion  of  hardened  masses  mixed  with 
mucus  and  sometimes  with  blood.  However,  the  suffering  con- 
tinued, and  was  especially  violent  after  the  administration  of 
purgatives,  even  in  small  doses  ;  the  abdominal  pain  became 
more  and  more  severe  ;  the  ischio-rectal  pain,  together  with 
the  neuralgia  which  he  had  at  the  commencement,  returned 
and  resisted  the  most  powerful  local  anodynes;  but  the  anal 
spasm  did  not  return.  In  spite  of  these  frightful  sufferings 
there  was  as  yet  little  loss  of  flesh. 

"  But  the  organism  could  not  long  withstand  such  sufferings 
and  emaciation  supervened  ;  there  was  fever  at  irregular  inter- 
vals, always  preceded  by  a  chill,  and  a  pale-yellowish  tint  to 
the  skin.  An  examination  of  the  rectum,  which  had  been  de- 
layed on  account  of  the  repugnance  of  the  patient,  was  ex- 
tremely painful  ;  but  instead  of  finding  as  before  a  considerable 

19 


290  DISEASES    OF    THE    RECTUM    AND    ANUS. 

dilatation  of  the  lower  extremity,  I  found  the  tissues  soft  and 
uneven,  giving  to  the  finger  the  sensation  of  folds  and  anfractu- 
osities,  in  a  way  that  without  a  speculum  examination  would 
have  led  one  to  believe  in  the  existence  of  condylomata  and  ex- 
tensive destruction  of  tissue  ;  but  by  the  aid  of  that  instrument 
I  was  able  to  prove  that  we  had  to  deal  with  an  hypertrophy  of 
the  mucous  membrane,  which  was  mammillated. 

"  This  condition  was  found  completely  surrounding  the  rec- 
tum and  reaching  as  high  as  the  eye  could  see.  The  sensation 
which  my  finger  experienced  could  not,  therefore,  be  due  to  a 
duplicature  of  the  hypertrophied  mucous  membrane.  A  sound 
introduced  into  the  rectum  passed  freely  eleven  centimetres, 
but,  arrived  at  that  point,  it  was  arrested  by  an  insurmountable 
obstacle,  and  caused  great  pain.  A  second  examination,  prac- 
tised about  a  fortnight  later,  permitted  me  to  observe  a  small 
tumor  on  the  right  side  of  the  intestine,  four  centimetres  above 
the  anus.  This  tumor  was  the  size  of  a  hazel-nut,  spherical, 
smooth,  somewhat  elastic,  and  indolent  even  to  pressure.  It 
was  absolutely  immovable,  and  did  not  seem  adherent  to  the 
mucous  membrane  beneath  which  it  lay.  But  all  these  details 
were  very  difficult  to  appreciate  well  on  account  of  the  hyper- 
trophy of  the  mucous  membrane  and  the  irregularities  of  its 
surface. 

"The  retraction  of  the  rectum  was  then  an  evident  fact,  re- 
vealed not  only  by  the  rational  symptoms,  but  by  the  physical 
examination  and  the  hypertrophic  thickening  of  the  mucous 
membrane.  But  the  diagnosis  of  the  nature  of  the  constriction 
still  remained  doubtful,  for  the  data  furnished  by  direct  exam- 
ination seemed  insufficient.  We  were  therefore  reduced  to 
making  a  diagnosis  by  exclusion,  and  rejecting  successively  the 
valves  of  mucous  membrane,  strictures  due  to  ulceration  or 
simple  inflammation,  excluding  also  the  idea  of  a  spasmodic  or 
venereal  stricture,  tubercular  stricture,  polypus,  and  haemor- 
rhoids, we  were  naturally  led  to  the  conclusion  that  we  were 
dealing  with  a  cancer.  However,  we  had  no  pathognomonic 
sign  on  which  to  base  this  diagnosis  ;  and  the  origin  and  evolu- 
tion of  the  disease  were  not  those  of  cancer,  the  march  of  which 
is  slow  and  rarely  takes  such  an  exceptionally  rapid  course. 
Tims,  hesitating  to  admit  a  cancer,  I  thought  of  syphilis.  But 
it  was  necessary  to  know  for  certain  whether  our  patient  was 
suffering  from  syphilis.     It  was  necessary  to  be  able  to  estab- 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  291 

lisli  by  well-observed  facts  that  a  syphilis  may  remain  latent 
nearly  nineteen  years  without  causing  any  species  of  manifes- 
tation. The  emaciation,  the  coloration  of  the  skin,  the  daily 
fever,  all  seemed  to  indicate  the  presence  of  cancer,  and  to  ex- 
clude the  idea  of  syphilis. 

"However,  the  powerlessness  of  art  in  the  presence  of  a 
heteroplastic  lesion  determined  me  to  attempt  an  anti-syphilitic 
treatment,  which  I  commenced  by  administering  large  doses  of 
iodide  of  potash.  After  twelve  days  of  this  treatment  the  pa- 
tient experienced  relief  of  all  the  worst  symptoms.  The  first  to 
yield  was  the  ischio-anal  pain,  which  for  some  time  had  been 
exceedingly  severe.  The  anal  tumor  diminished  little  by  little, 
the  mucous  membrane  subsided,  there  were  several  normal  pas- 
sages, the  colic  became  less  frequent  and  less  severe,  and  disap- 
peared finally  after  some  violent  pain  which  the  evacuation  of  a 
considerable  quantity  of  hard  faecal  matter  provoked.  From 
that  time  the  passages  were  daily  and  easy,  the  local  symptoms 
became  definitely  better.  The  flesh  returned,  the  fever  disap- 
peared, with  it  disappeared  the  yellowish  tint  of  the  integument, 
and  at  the  end  of  three  months  the  patient  was  completely 
cured." 

This  case  is  also  quoted  by  Molliere '  in  full,  as  proof  of 
what  may  be  accomplished  by  anti-syphilitic  treatment  in 
syphilitic  stricture.  He  remarks  that  one  sucli  case  seems  to 
him  to  pass  all  comment,  and  to  prove  what  caution  should  be 
used  in  the  diagnosis  of  organic  disease.  That  nothing,  in  fact, 
was  more  improbable  than  the  syphilitic  character  of  the  lesions 
of  this  patient,  and  that  specifics  saved  him  from  certain  death. 
He  asks  :  "Is  not  one  authorized,  in  the  presence  of  one  such 
extraordinary  fact,  to  lay  down  the  absolute  rule  that  iodide 
of  potash  should  be  employed  in  all  neoplastic  lesions  of  the 
rectum  ?" 

To  my  own  mind  the  case  conveys  a  very  different  lesson 
from  the  one  intended.  It  seems  to  me  to  prove  nothing  with 
regard  to  the  effect  of  internal  medication  in  syphilitic  stricture, 
and  to  be  one  more  example  of  a  diagnosis  of  stricture  based 
upon  the  fact  that  a  bougie  met  with  an  obstruction  at  a  point 
beyond  the  limit  of  touch  and  vision.  It  may  be  a  case  of 
syphilitic  stricture  cured  by  treatment,  but  the  history  does  not 
prove  it. 

1  Op.  cit ,  p.  306. 


292  DISEASES    OF   THE    RECTUM    AND    ANUS. 

There  are  various  means  by  which  the  comfort  of  these  suf- 
ferers may  be  greatly  increased  without  recourse  to  operative 
treatment — and  since  in  many  cases  the  surgeon  is  limited  to 
these  means  in  his  efforts  to  afford  relief,  it  is  well  that  th^y 
should  receive  careful  attention.  The  most  effectual  of  them 
will  be  found  to  be  a  careful  regulation  of  the  diet,  the  admin- 
istration of  laxatives  on  occasion,  and  rest.  The  diet  should 
consist  mostly  of  fluids,  preferably  milk.  If  milk  is  complained 
of,  soups  may  be  substituted.  A  certain  amount  of  farinaceous 
food  may  also  be  allowed,  such  as  toast,  crackers,  and  mush  ; 
but  milk  is  the  basis  of  the  diet,  and  the  other  things  are  only 
intended  to  make  that  diet  endurable.  Many  patients  will  as- 
sert from  the  outset  that  they  cannot  take  milk,  but  nearly  all 
can  take  it,  and  considerable  quantities  of  it  daily  for  an  in- 
definite period,  if  a  little  care  is  exercised  in  its  administration. 

The  bowels  should  move  daily  without  straining.  Should 
any  medication  be  necessary  to  secure  this  daily  evacuation  a 
mild  laxative  will  be  found  all-sufficient.  The  mineral  waters, 
or  Rochelle  or  Glauber's  salts  answer  every  purpose.  Purga- 
tives are  always  contra-indicated  in  stricture  of  any  variety, 
because  they  cause  straining  and  tenesmus,  increase  the  ten- 
dency to  congestion  and  its  consequences,  and  because  where 
obstruction  actually  exists  or  is  threatened,  they  may  do  great 
harm  by  exciting  violent  peristaltic  action  in  an  already 
weakened  and  ulcerated  bowel.  The  opposite  condition  of 
diarrhoea  is  more  difficult  to  meet  and  often  cannot  be  controlled 
by  direct  medical  treatment,  depending  as  it  does  on  the  ulcera- 
tion associated  with  the  stricture.  It  is  best  met  by  diet,  rest 
in  the  recumbent  posture,  and  bismuth  with  morphine. 

The  general  strength  of  these  patients  is  to  be  supported 
in  every  possible  way,  and  in  all  of  them  where  it  can  be  borne 
cod-liver  oil  will  be  found  to  answer  a  good  purpose. 

When  obstruction  actually  exists,  much  may  be  done  in  the 
way  of  general  treatment  before  resorting  to  operation.  Food 
-hoi ild  be  almost  absolutely  suspended  ;  opium  should  be  given 
in  large  doses,  to  allay  the  peristaltic  action  of  the  intestine, 
and  large  poultices  covering  the  abdomen  will  be  found  to  give 
great  relief  to  fclie  suffering.  Dr.  Norman  Kerr  has  derived 
great  benefit  from  the  administration  of  the  extract  of  bella- 
donna in  doses  of  one  or  two  grains  at  short  intervals,  in  this 
condition,  but  the  rationale  of  its  operation  is  not  understood. 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  293 

No  purgatives  should  be  administered,  and  the  bowel  should 
not  be  tapped  with  the  aspirator.  The  dangers  of  this  measure 
have  already  been  pointed  out. 

By  these  means,  combined  possibly  with  gentle  dilatation, 
the  life  of  a  patient  may  be  prolonged  in  comfort.  I  have  often 
been  agreeably  surprised  at  the  happy  results  of  such  measures, 
where  operative  interference  was  either  declined  or  contra-indi- 
cated, and  they  can  never  be  dispensed  with,  though  an  opera- 
tion be  performed. 

The  various  surgical  procedures  at  our  command  for  over- 
coming stricture  of  the  rectum  may  be  considered  in  the  follow- 
ing order  :  1.  Dilatation.     2.  Division.     3.  Colotomy. 

1.  Dilatation. — This  may  be  either  gradual  or  sudden,  par- 
tial or  complete.  The  use  of  bougies  for  gradual  dilatation  is 
an  example  of  a  good  practice  originating  in  false  ideas.  It 
was  first  adopted  with  the  idea  of  destroying  the  stricture  by  the 
effect  of  medicinal  substances  applied  in  this  way  ;  experience, 
however,  soon  proved  that  simple  bougies  were  not  less  effica- 
cious than  medicated  ones,  and  the  improvement  was  then  sup- 
posed to  be  due  merely  to  the  mechanical  stretching  of  the  part, 
and  the  instruments  were  introduced  as  often,  and  allowed  to 
remain  in,  as  long  as  possible,  an  idea  still  very  popular.  But 
as  Syme1  pointed  out,  "it  is  the  effusion  of  organizable  matter 
in  the  cellular  texture  of  the  part  which  causes  the  stricture, 
and  it  is  the  absorption  of  this  deposit  which  removes  the  disease. 
The  bougie,  by  its  pressure,  excites  the  action  of  absorption  ; 
and  if  the  pressure  be  too  great,  too  long  continued,  or  too 
frequently  repeated,  there  will  be  a  great  risk  of  causing  more 
than  sufficient  irritation  for  the  purpose,  and  of  inducing  again 
the  very  condition  it  is  desired  to  counteract,  the  consequences 
of  which  must  be  a  confirmation  and  increase  of  the  disease." 

The  rules  which  should  guide  the  surgeon  in  this  method  of 
treatment  are  now  well  understood  and  generally  admitted. 
The  dilatation  should  be  intermittent,  and  not  constant.  At- 
tempts at  constant  dilatation  by  means  of  a  bougie  of  any  sort 
which  shall  remain  permanently  in  place,  generally  result  either 
in  failure  or  actual  disaster.  They  are  not  well  borne  by  the 
patient,  and  when  their  use  is  persisted  in,  in  spite  of  the  pro- 
test which  nature  is  pretty  sure  to  make,  the  rectum  becomes 

:Op.  cit.,  p.  120. 


294  DISEASES    OF   THE    RECTUM    AND    ANUS. 

irritable,  the  suffering  is  greatly  increased,  and  the  patient  is 
exposed  to  the  risk  of  peritonitis  and  cellulitis. 

The  dilatation  should  never  be  forced.  A  bougie  should  be 
chosen  which  will  readily  pass  the  obstruction  without  stretch- 
ing, and  if  there  be  any  doubt  in  the  operator's  mind  as  to  the 
proper  size  of  the  instrument  to  be  used,  let  one  be  selected 
which  is  too  small  rather  than  too  large.  The  instrument  should 
seldom  be  passed  more  than  every  alternate  day,  and  once  a 
week  may  be  often  enough.  Little  is  gained  by  allowing  it  to 
rest  for  any  length  of  time  within  the  constriction. 

Practised  in  this  way,  much  good  may  be  done  by  this  treat- 
ment. The  patient  may  be  greatly  relieved,  and  made  very 
comfortable  ;  but  it  must  be  continued  indefinitely.  For  this 
reason,  I  suppose  it  is  not  infrequently  used  under  false  pre- 
tences in  cases  of  hypothetical  stricture  in  hypochondriacal 
patients  ;  and  most  of  the  reported  cases  of  cure  will  be  found 
reported  by  the  laity.  It  has  happened  to  me  more  than  once 
not  to  be  able  to  find  any  stricture  after  a  patient  had  sub- 
mitted to  a  long  course  of  supposed  dilatation,  and  there  is  but 
one  way  of  convincing  the  patient  under  such  circumstances. 
It  consists  simply  in  passing  a  full-sized  instrument  its  whole 
length  into  the  bowel. 

In  cases  where  the  stricture  is  associated  with  much  ulcera- 
tion, dilatation  by  bougies  is  very  apt  to  make  matters  worse 
instead  of  better,  and  in  such  cases  I  seldom  employ  it  in  my 
own  practice,  and  have  seen  much  suffering  caused  by  it  in  the 
practice  of  others. 

The  treatment  by  gradual  dilatation,  perhaps  on  account  of 
the  recent  great  advances  which  have  been  made  in  the  treat- 
ment of  stricture,  has,  to  a  certain  extent,  been  superseded  by 
more  radical  measures.  It  is  not  long  since  a  well-written 
article  on  rectotomy  in  one  of  our  periodicals  was  begun  by  the 
statement  that  the  treatment  of  stricture  by  dilatation  was  ac- 
knowledged to  be  a  failure.  This  is  by  no  means  the  case.  The 
measure  may  not  be  curative,  but  it  is,  perhaps,  as  valuable 
a  palliative  as  is  at  the  command  of  the  surgeon.  It  need  not 
always  be  done  with  a  bougie  ;  for  the  patient's  own  finger  or 
thai  of  a  careful  nurse  is  often  better  than  any  instrument.  It 
is  applicable  to  all  structures,  malignant  or  benign,  which  are 
within  reach  of  the  anus.  When  the  disease  is  high  up,  it 
is   not  free  from   danger,  and   can  scarcely  be  recommended, 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  295 

on  account  of  the  uncertainty  and  difficulty  of  its  applica- 
tion. 

I  have  said  that  this  treatment  by  gradual  dilatation  was 
not  curative,  and  must  be  continued  indefinitely.  I  have  seen 
no  exceptions  to  this  rule,  though  many  of  them  are  reported. 
In  years  gone  by,  this  treatment  and  that  of  forcible  dilatation 
or  divulsion  were  about  the  only  means  of  dealing  with  this 
affection.  Now  we  have  better  ones  which  will  shortly  be  de- 
scribed. 

Divulsion. — The  dilatation,  instead  of  being  gradual,  may 
be  sudden  and  complete.  For  this  purpose  various  instruments 
have  been  invented,  all  of  them  with  the  idea  of  tearing  open 
the  constriction  by  the  use  of  a  considerable  amount  of  force. 
One  of  these  is  shown  in  Figure  80.     More  recently,  advantage 


Fig.  80. 


has  been  taken  of  fluid  pressure,  and  an  instrument  has  been 
invented  by  Wales,  which  is  shown  in  Figure  81. 

Of  all  the  instruments  for  forcible  dilatation,  this  is  perhaps 
the  best.  There  are  now  several  cases  on  record  where  forcible 
stretching  with  the  fingers,  either  with  or  without  previous 
nicking  with  a  knife,  has  been  followed  by  immediate  relief  to 
obstruction  and  faecal  accumulation.1 

What  may  be  accomplished  by  this  method  is  well  shown  in 
the  following  successful  case  from  Smith.2  "  I  was  called  by 
Dr.  Vine  to  see  a  military  officer,  aged  forty,  who  had  returned 
from  India  in  the  most  miserable  plight.  He  had  suffered  for 
several  years  from  chronic  diarrhoea,  and  had  not  got  relief  from 
any  measures,  and  six  months  previously  he  had  been  recom- 
mended by  a  medical  board  to  go  by  sea  to  England.  On  his 
arrival  at  Southampton,  on  his  way  to  Edinburgh,  his  native 
town,  he  was  so  ill  that  he  determined  to  stop  in  London,  and 
when  he  arrived  there  he  sent  for  Dr.  Vine,  who,  on  hearing 

1  Smith,  op.  cit.  Dr.  J.  M.  Matthews,  of  Louisville,  Ky.,  has  recorded  one  re- 
markably successful  case  of  this  kind. 

2  Surgery  of  the  Rectum. 


296 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


his  history,  at  once  suspected  something  wrong  with 
turn,  and  making  an  examination,  found  an  obstruction 


his  rec- 
I  was 
5 


Fig.  81.— Wales's  Dilators. 

requested  to  see  him,  and  I  found  the  patient  exactly  in  the 
condition  of  one  suffering  from  strangulated  hernia  ;   he  was 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  297 

constantly  vomiting,  complaining  of  pain,  and  the  countenance 
was  anxious,  and  he  was  much  emaciated  ;  the  abdomen  was 
immensely  distended,  and  it  was  clear  that,  if  some  relief  were 
not  soon  given,  this  gentleman  would  die. 

"In  conjunction  with  Dr.  Tine,  I  made  a  most  careful  ex- 
amination, and  I  found,  on  introducing  the  finger  into  the 
bowel  as  far  as  possible,  that  it  met  with  an  obstruction,  but 
after  some  time  I  discovered  what  appeared  to  be  the  opening 
of  the  stricture,  more  like  a  dimple  than  aught  else.  I  was  en- 
abled to  introduce  through  this  a  No.  10  gum-elastic  catheter, 
and  through  this  instrument  some  faecal  matter  and  air  came. 
I  was  thus  made  to  see  that  I  had  got  beyond  the  stricture. 

"  On  the  following  day  the  patient  was  placed  under  chlor- 
oform, and  I  guided  a  long,  straight,  probe-pointed  knife  very 
carefully  along  the'  side  of  my  left  index  finger,  and  fortunately 
got  its  point  into  the  orifice  of  the  stricture.  I  nicked  this  on 
either  side,  and  then  got  the  point  of  my  finger  into  the  obstruc- 
tion, and  dilated  the  orifice  as  much  as  I  could,  whereupon  an 
enormous  quantity  of  faecal  matter  was  emitted,  deluging  the 
bed,  and  placing  myself  and  my  assistants  in  a  most  unenviable 
position.  The  abdomen  became  quite  flat,  and  the  patient  be- 
came at  once  immediately  relieved.  No  bad  results  followed 
this  operation  ;  in  three  days  we  commenced  dilatation  by 
bougies,  and  I  was  soon  enabled  to  pass  a  full-sized  rectum- 
bougie  through  the  stricture.  In  a  fortnight  I  took  my  leave 
of  the  patient,  recommending  Dr.  Vine  to  pass  the  bougie  daily. 
I  heard  a  few  weeks  afterward  that  the  patient  had  gone  to 
Edinburgh  convalescent,  and  able  to  introduce  the  bougie  for 
himself." 

In  spite  of  a  few  such  successful  cases  as  the  one  above,  this 
method  of  treatment  has  but  few  upholders,  because  it  has  been 
found  to  possess  no  advantages  over  more  gradual  dilatation, 
and  to  be  in  itself  by  no  means  devoid  of  danger.  The  dangers 
are  haemorrhage,  laceration  and  rupture  of  the  bowel,  periton- 
itis, and  abscess.  The  relief  obtained  is  not  permanent,  and 
the  operation  involves  the  subsequent  use  of  gradual  dilatation 
to  preserve  the  calibre  gained.  Even  when  applied  to  the  lower 
three  inches  of  the  bowel,  the  operation  is  rough,  uncertain, 
and  unsurgical,  and  above  this  point  it  is  scarcely  admissible. 
Nevertheless,  it  has  occasionally  served  a  good  purpose,  and  a 
few  happy  results  are  recorded  in  cases  of  linear  contraction. 


298  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Division  of  the  Stricture. — The  practice  of  nicking  a  linear 
stricture  in  two  or  three  places  as  a  first  step  in  the  treatment 
by  dilatation  is  a  good  one,  and  generally  devoid  of  danger.  It 
can  usual]}7  be  done  entirely  by  the  sense  of  touch  with  a 
straight,  blunt-pointed  bistoury  passed  along  the  left  index 
finger  as  a  guide. 

The  operation  of  internal  proctotomy  consists  in  dividing 
the  whole  of  the  stricture  tissue  in  the  median  line,  either  an- 
teriorly or  posteriorly.  It  is  called  internal  because  the  inci- 
sion is  confined  within  the  rectum  and  does  not  involve  the 
sphincter,  and  it  is  generally  performed  with  the  knife  in  pref- 
erence to  the  cautery  or  ecraseur. 

Regarding  this  operation  there  is  not  very  much  to  be  said. 
It  involves  no  new  principle  of  treatment,  and  would  seem  to 
rank  rather  with  the  older  procedures,  such  as  nicking  and 
dilatation,  than  as  a  substitute  for  colotomy.  There  have  been 
many  unpublished  cases,  especially  in  New  York,  and  I  should 
probably  express  the  general  feeling  of  the  profession  were  I  to 
say  that  it  is  not  looked  upon  with  very  great  favor.  Though 
at  first  sight  it  might  appear  less  serious  than  the  external 
operation,  it  is  probably  the  more  dangerous  of  the  two — the 
sphincter  preventing  the  free  discharge  from  the  wound  and  in- 
creasing in  this  way  the  liability  to  pelvic  inflammation.  This 
muscle  should  at  least  be  stretched  as  a  primary  step  in  the 
operation,  and  when  possible,  a  large  drainage-tube  should  be 
left  in.  The  danger  of  haemorrhage  is  not  very  great  when  the 
incision  is  confined  to  the  median  line,  but,  should  there  be 
trouble  from  this  cause,  the  advantage  of  a  free  external  wound 
in  controlling  it  will  at  once  be  manifest.  When  the  cut  is  an- 
terior as  well  as  posterior,  the  anatomical  relations  must  be 
borne  in  mind,  lest  the  peritoneum  in  the  female,  or  the  bladder 
in  the  male,  be  wounded.  The  following  case  represents  my 
entire  experience  with  the  operation,  which  I  abandoned  after 
once  trying,  being  convinced  of  the  advantages  of  the  external 
excision,  next  to  be  described. 

Case.    Internal  Proctotomy. — Mrs. ,  aged  twenty-six. 

This  patient  was  a  woman  with  a  syphilitic  history.  The  stric- 
ture was  of  eiglit  years'  growth,  and  had  previously  been 
treated  both  by  nicking  and  by  gradual  dilatation.  As  a  result 
of  this  treatment,  she  describes  an  attack  of  "  inflammation  of 
the  bowels,"    which   made  her  very  dangerously   sick.     The 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  299 

stricture  was  two  and  one-half  inches  from  the  anus,  was  of 
just  sufficient  calibre  to  engage  the  end  of  the  index  finger,  and 
did  not  involve  more  than  one  inch  of  the  bowel,  though  there 
was  the  usual  amount  of  ulceration  above  it. 

I  divided  the  stricture  by  a  single,  deep,  posterior  incision, 
which  did  not  implicate  the  sphincter,  and  the  operation  was 
followed  by  an  attack  of  pelvic  peritonitis,  which  very  nearly 
cost  the  patient  her  life.  This  may  have  been  due  to  the  opera- 
tion, or  it  may  have  been  due  to  attempts  at  subsequent  dilata- 
tion, which  was  begun  early  and  followed  with  perhaps  too  great 
vigor ;  but  it  was  certainly  excited  by  the  patient  leaving  her 
bed,  going  down-stairs,  indulging  freely  in  wine,  and  submit- 
ting to  the  embraces  of  her  lover. 

Three  months  after  the  operation,  I  completely  lost  track  of 
the  case.  At  that  time  the  calibre  of  the  stricture  was  so  much 
increased  as  to  permit  of  easy  digital  examination  of  the  parts 
above.  The  increased  size  seemed  due  entirely  to  a  deficiency 
in  the  old  cicatricial  tissue  at  the  point  of  incision,  the  rest  of 
the  circumference  of  the  part  having  much  the  same  feel  as  be- 
fore the  operation.  The  act  of  defecation  was  much  less  pain- 
ful, and  her  condition  was  altogether  much  better. 

I  never  counted  the  case  as  proving  anything  concerning  the 
value  of  the  operation  until  a  few  months  ago,  and  more  than 
four  years  after  its  performance.  In  fact,  I  had  little  doubt 
that  the  contraction  had  returned,  and  supposed  that  the  pa- 
tient had  either  succumbed  to  the  disease  or  submitted  to  colo- 
tomy.  At  that  time,  however,  the  woman  was  in  perfect  health 
and  spirits,  and  since  then  I  have  thought  better  of  the  opera- 
tion. I  would  have  given  much  for  a  rectal  examination  after 
so  long  an  interval,  but  it  could  not  be  obtained. 

Other  cases  of  similar  operations  have  been  reported  in  this 
country  with  equally  good  results.1 

External  proctotomy  involves  not  only  the  division  of  the 


1  Whitehead — Old  fibrous  stricture  ;  anterior  and  posterior  incision  with  bistoury, 
followed  by  dilatation.  Two  months  later,  much  improved ;  passages  large  and  nat- 
ural;  dilatation  continued.  Amer.  Jour.  Med.  Sc,  Jan.,  1871.  Lente — Fibrous 
stricture  and  fistula ;  incision  followed  by  dilatation.  Three  months  later,  much  re- 
lieved, with  prospect  of  entire  cure  by  continuing  the  use  of  bougies.  Amer.  Jour. 
Med.  Sc,  July,  1873.  Beane — Probably  syphilitic;  incision  both  anterior  and  pos- 
terior, followed  by  use  of  dilators.  Seven  months  after,  cure  of  ulceration  and  of 
many  bad  symptoms,  but  tendency  to  recontraction.  Amer.  Jour.  Med.  Sc,  April, 
1878. 


300  DISEASES    OF    THE    RECTUM    AND    ANUS. 

stricture,  but  of  all  the  parts  below,  including  the  anus.  This 
is  the  operation  usually  accredited  to  Nelaton,  and  more  re- 
cently advocated  by  Verneuil,  Panas,  and  others.  It  may  be 
performed  in  several  ways,  and  with  the  knife,  galvano-cautery, 
or  ecraseur.  The  operations  with  the  galvano-cautery  and 
ecraseur  were  invented  by  Verneuil,1  and  have  been  practised 
by  him  more  than  by  any  other  surgeon. 

The  operation,  as  performed  by  him,  consists  in  passing  the 
left  index  finger  through  the  stricture  as  a  guide,  and  then 
plunging  a  trocar  from  a  point  in  the  median  line,  just  in  front 
of  the  tip  of  the  coccyx,  into  the  rectum,  on  to  the  tip  of  the 
finger  above  the  stricture.  After  drawing  out  the  trocar  a  fine 
bougie  is  passed  through  the  canula  into  the  rectum,  and 
brought  out  at  the  anus.  Removing  the  canula,  the  bougie  is 
replaced  by  the  chain  of  the  ecraseur,  and  the  operation  is  com- 
pleted. 

The  same  section  may  be  accomplished  by  repeated  strokes 
of  the  galvano-cautery  or  thermo-cauteiy  knife.  Both  these 
measures  are  intended  simply  to  prevent  haemorrhage,  and  have 
no  other  advantage  over  the  knife,  and  by  any  of  the  methods 
all  of  the  stricture  tissue  and  the  parts  below  may  be  divided. 

Nelaton's  method  was  the  simplest  of  all,  and  was  to  intro- 
duce the  left  index  finger  as  far  as  the  stricture,  and  with  this 
as  a  guide,  to  pass  in  a  blunt  bistoury,  and  divide  all  the  soft 
parts  below  the  stricture  as  nearly  as  possible  in  the  median 
line.  By  pulling  open  the  lips  of  this  incision,  the  stricture 
comes  plainly  into  view,  and  may  be  divided  by  a  second  in- 
cision. 

In  performing  this  operation  either  the  knife  or  the  cautery 
may  be  used.  Formerly  I  preferred  the  knife,  and  had  one 
especially  adapted  for  the  purpose,  which  is  shown  in  Fig.  82. 

It  is  simply  the  lithotomy  knife  of  Blizard,  made  heavier  in 
the  back  and  at  the  handle,  for  with  an  ordinary  bistoury  there 
is  great  risk  of  breaking  the  blade  in  the  midst  of  the  stricture 
tissue,  which  is  often  as  hard  as  cartilage,  and  thus  having  an 
awkward  accident.     The  blunt  point  on  the  end  of  the  blade  is 


1  Verneuil :  Dch  r<'-tr:ci88ement8  de  lapartie  inferietire  du  rectum,  etde  leur  traite- 
ment  curatif  on  palliatif  par  la  reetotomie  lineaire,  ou  section  longitudinale  de  l'intes- 
tin  a  l'aide  de  l'ccraseur.  Gaz.  des  Hop.,  October  2(5,  29  ;  November  7,  9,  12,  1(5,  19, 
1872.  Traitement  palliatif  du  cancer  du  rectum  au  moyen  de  la  reetotomie  lineaire. 
Gaz.  Ilebdom.,  March  27,  1874. 


NON-MALIGNANT    STRICTURE    OF   THE    RECTUM.  301 

a  great  convenience  in  passing  the  knife  along  the  index  finger, 
avoiding,  as  it  does,  all  risk  of  wounding  the  operator. 

The  best  position  for  the  patient  is  the  lithotomy  position, 
and  the  whole  incision  may  be  made  at  one  stroke.  The  blade 
should  be  passed  fairly  through  the  stricture  before  the  cutting- 
is  begun,  then  the  stricture  is  divided  completely,  as  near  as 
possible  in  the  median  line  posteriorly,  and  finally  the  incision 
is  continued  downward  and  outward,  growing  deeper  as  it 
approaches  the  perinaeum,  till  all  the  soft  parts  are  severed 
between  the  anus  and  the  tip  of  the  coccyx.  In  this  way  a 
large  triangular  wound  is  made,  the  apex  being  within  the  rec- 
tum, above  the  stricture,  and  the  base  at  the  skin,  and  all  the 
stricture  tissue  is  completely  cut  through. 

There  will  generally  be  a  free  gush  of  blood  when  the  cut  is 
made,  and  the  rectum  should  at  once  be  packed  in  the  manner 
already  described,  without  waiting  to  try  any  other  method  of 


Fig.  82. — Proctotomy  Knife. 

stopping  the  bleeding.  This  is  a  precaution  which  should  never 
be  omitted. 

It  was  this  haemorrhage,  and  the  trouble  of  removing  the 
lint  with  which  it  was  almost  always  necessary  to  stuff  the  rec- 
tum, which  first  led  me  to  operate  with  the  thermo-cautery, 
which  I  now  greatly  prefer.  The  bleeding  is  absolutely  noth- 
ing, and  the  wound  is  dressed  by  its  own  eschar,  thus  saving 
much  distress  to  the  patient. 

This  operation  may  be  modified  in  various  ways  to  fulfil  any 
special  indication.  In  extensive  cancerous  disease  I  have  some- 
times made  two  such  cuts,  and  taken  out  a  considerable  mass  of 
the  growth  between  them,  merely  for  the  purpose  of  opening 
the  canal. 

It  may  be  asked,  Why  should  so  large  an  incision  be  made, 
and  so  much  tissue  be  divided  below  the  actual  disease  ?  The 
answer  is  simple.  In  the  first  place,  this  incision  provides  for 
free  drainage  and  discharge  in  the  most  effectual  of  all  ways,  by 
furnishing  a  dependent  gutter-shaped  opening  which  cannot  be- 
come closed.  This  is  better  than  any  number  of  drainage-tubes, 
and  it  is  this  alone  which  makes  the  external  operation  a  safer 
one  than  the  apparently  slighter  internal  incision. 


302  DISEASES    OF   THE    RECTUM   AND    ANUS. 

In  the  second  place,  by  this  incision  the  sphincter  is  com- 
pletely divided,  and  another  great  point  is  gained.  The  opera- 
tion we  are  now  considering,  it  should  be  remembered,  is  noth- 
ing less  than  a  substitute  for  colotomy  in  the  same  class  of 
severe  cases  for  which  that  operation  is  generally  considered  the 
only  relief.  One  point  which  is  exceedingly  well  brought  out 
by  a  study  of  these  cases  is  the  important  part  played  by  the 
sphincter  muscle  in  tlie  sufferings  accompanying  severe  cases  of 
stricture  and  ulceration,  and  the  relief  which  may  be  obtained 
by  its  simple  division  without  interference  with  the  stricture 
itself. 

In  one  case  of  Verneuil's,  for  example,  there  was  a  stricture 
high  up,  and  yet,  under  a  mistaken  diagnosis  of  spasmodic 
stricture  at  the  anus,  the  sphincter  was  cut  through  with  the 
galvano-cautery,  while  the  real  cause  of  the  trouble  was  un- 
touched, and  yet  there  was  entire  relief  from  suffering.  The 
same  experience  has  been  repeated  often  enough  to  establish  the 
general  principle,  that  free  division  of  the  sphincter  is  not  only 
a  justifiable  therapeutic  measure  for  the  relief  of  the  pain  at- 
tendant upon  either  benign  or  malignant  stricture  or  ulceration, 
but  is  often  the  best  means  at  the  surgeon's  command  for  allay- 
ing suffering. 

By  the  external  operation,  then,  the  obstruction  is  divided, 
and  one  great  cause  of  suffering  is  abolished,  and  both  are  ef- 
fected by  the  same  stroke  of  the  knife. 

The  after-treatment  of  the  incision  is  very  simple.  When 
the  rectum  has  been  tightly  packed  with  picked  lint,  it  will 
usually  cause  more  or  less  uneasiness  on  the  following  day, 
unless  the  patient  be  under  the  influence  of  opium.  For  this 
reason,  I  generally  remove  enough  of  it  on  the  following  day  to 
give  the  patient  ease,  and  the  remainder  is  allowed  to  remain 
imtil  suppuration  has  commenced.  It  may  usually  all  be 
picked  out  by  the  third  or  fourth  day  without  causing  any  pain. 
The  subsequent  treatment  of  the  incision  itself  consists  wholly 
in  cleanliness,  which  may  be  obtained  by  gently  syringing  the 
part  with  warm  water  and  a  little  carbolic  acid.  No  particular 
attention  need  be  given  to  regulating  the  passages.  The  first 
one  after  the  operation  will  often  be  the  only  comfortable  one 
the  patient  has  experienced  for  years,  and  unless  there  is  some 
special  reason  for  interference,  they  may  be  left  entirely  to 
nature. 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  303 

The  cases  which  follow  will  give  a  very  fair  idea  of  what 
may  be  hoped  for  from  this  method  of  treatment. 

Case.     External  Proctotomy . — Mrs.  ,  aged  thirty-five, 

mother  of  one  child  twelve  years  old.  The  patient  had  always 
suffered  from  obstinate  constipation,  and  several  years  ago  was 
relieved  artificially  of  impaction  of  faeces.  Her  husband,  a  phy- 
sician, assures  me  that  there  is  no  venereal  history,  nor  is  there 
any  reason  to  suspect  any  such.  The  symptoms  of  rectal  trouble 
began  six  years  after  marriage,  at  which  time  she  was  operated 
upon  for  large  internal  haemorrhoids.  Soon  after  this  she  began 
to  suffer  with  the  usual  symptoms  of  ulceration  of  the  rectum. 

The  examination  revealed  advanced  ulceration  of  the  whole 
circumference  of  the  rectum,  with  a  stricture  about  an  inch  and 
a  half  up,  which  just  admitted  the  end  of  the  index  finger.  In 
connection  with  the  stricture  there  were  two  fistulas.  For  this 
condition  the  patient  had  submitted  to  the  usual  treatment  by 
dilatation,  but  without  relief.  Her  general  condition  was  such 
as  is  usually  seen  in  advanced  rectal  disease.  She  had  lost  flesh 
and  appetite,  and  the  suffering  was  extreme.  What  she  most 
dreaded  was  an  action  of  the  bowels,  so  great  was  the  pain  at- 
tendant upon  it. 

The  operation  which  I  have  described  was  performed.  One 
of  the  fistulae  was  also  cut,  but  the  other  was  left  to  the  chance 
of  spontaneous  closure,  since  it  communicated  with  both  rectum 
and  vagina,  and  the  usual  operation  for  recto-vaginal  fistula 
would  have  been  necessary  had  any  interference  been  practised. 
The  operation  was  attended  with  considerable  haemorrhage, 
which  was  controlled  by  stuffing  the  rectum  with  picked  lint, 
after  the  ulcerated  surfaces  both  above  and  below  the  stric- 
ture had  been  renovated  by  scraping  them  with  the  handle  of  a 
scalpel. 

The  subsequent  treatment  consisted  merely  in  absolute  rest 
in  bed  and  milk  diet,  with  a  dressing  of  the  wound  by  the  in- 
troduction of  picked  lint.  No  attempt  was  made  at  passing  a 
bougie,  and  the  stricture  was  left  entirely  to  itself.  The  imme- 
diate effect  of  the  operation  was  a  most  marked  and  satisfactory 
relief  of  the  most  painful  symptoms.  The  passages  were  invol- 
untary, but  were  painless  and  always  preceded  by  a  warning 
sensation,  which  gave  the  patient  ample  time  to  prepare  herself. 
At  the  end  of  six  weeks  she  had  improved  greatly  in  general 
condition,  and  was  more  comfortable  than  at  any  time  since  the 


304  DISEASES    OF    THE    RECTUM    AND    ANUS. 

trouble  began.  The  passages  were  of  normal  shape  and  oc- 
curred painlessly  once  a  day.  They  were  under  the  control  of 
the  will,  but  there  was  incontinence  of  wind.  In  this  condition 
the  patient  returned  to  her  home  in  the  West  under  the  care  of 
her  husband. 

Six  months  later  she  again  came  to  New  York  for  treat- 
ment, not  from  any  return  of  the  pain,  but  because  of  the  dis- 
charge from  the  bowel,  and  the  occasional  annoyance  which 
arose  from  the  incontinence  of  wind.  Her  general  condition 
was  excellent,  and,  except  for  the  two  things  mentioned,  she 
would  have  considered  herself  in  perfect  health.  An  examina- 
tion showed  a  very  marked  decrease  and  softening  down  in  the 
stricture  tissue  ;  the  wound  made  with  the  knife  had  never  en- 
tirely healed,  the  patient  having  exercised  freely  and  constantly 
while  at  home,  and  there  were  two  distinct  lines  of  ulceration 
within  the  anus  :  one  on  the  anterior  surface,  superficial,  about 
half  an  inch  broad  and  an  inch  and  a  half  long ;  the  other,  at 
the  site  of  the  cut  behind,  deeper,  and  running  further  up  the 
bowel.  Otherwise  the  old  ulceration  was  entirely  healed,  and  its 
site  marked  by  a  thin,  shining  bluish- white  cicatricial  surface. 

Attention  was  at  once  turned  to  the  treatment  of  this  ulcera- 
tion. The  patient  was  put  upon  almost  absolute  milk  diet,  and 
after  a  while  was  also  confined  absolutely  to  her  bed.  The 
remnant  of  the  old  incision  was  induced  to  heal  by  daily  dress- 
ings of  lint  and  balsam  of  Peru,  and  the  ulceration  above  was 
treated  by  applications  of  bismuth,  opium,  nitrate  of  silver, 
balsam  of  Peru,  iodoform,  and  oxide  of  zinc,  alone  and  in  com- 
bination. At  the  end  of  a  couple  of  months  she  was  so  nearly 
well  that  attention  was  turned  to  the  recto-vesical  fistula.  The 
openings  into  the  rectum  and  vagina  were  both  small,  but  there 
was  a  considerable  abscess  cavity  in  the  recto-vaginal  wall 
which  discharged  into  each  canal.  This  cavity  was  freely  laid 
open  into  the  rectum.  At  the  end  of  three  months  the  ulcera- 
tion on  the  anterior  wall  of  the  rectum  had  entirely  healed,  that 
on  the  posterior  wall  had  nearly  healed,  the  incision  had  cica- 
trized, and  the  abscess  cavity  had  closed  except  an  exceedingly 
fine  and  fcortnous  canal  leading  from  the  rectum  into  the  vagina. 
The  discharge  from  the  rectum  had  practically  ceased,  and  in 
llii<  condition,  which  certainly  warranted  a  prognosis  of  com- 
plete and  speedy  recovery,  she  returned  to  her  home  to  continue 
the  treatment  for  a  few  weeks  longer,  till  she  should  be  entirely 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  dOo 

well.  Four  years  later  I  again  heard  from  her,  and  the  report 
was  most  favorable. 

This  case  is  certainly  worthy  of  a  careful  consideration. 
When  the  lady  applied  to  me,  all  the  supposed  resources  of 
rectal  surgery  had  been  exhausted  except  colotomy.  I  do  not 
think  I  exaggerate  when  I  say  that  most  surgeons  would  have 
at  once  decided  in  favor  of  colotomy,  and  would  have  been  jus- 
tified, of  course,  in  so  deciding,  for  colotomy  is  still  the  recog- 
nized mode  of  treatment  in  these  cases.  In  my  own  mind,  colo- 
tomy was  always  present  as  the  dernier  ressort,  but  having  tried 
proctotomy  in  several  instances,  and  been  more  or  less  satisfied 
with  its  results,  I  determined  to  make  this  a  test  case.  The  re- 
sult was  most  happy,  and  yet  there  is  nothing  exceptional  in 
that  result,  though  the  great  tractability  of  the  patient,  and  her 
determination  to  do  all  that  was  asked  of  her,  alone  rendered  it 
possible. 

Case.  External  Proctotomy. — Mary  P ,  aged  thirty-five, 

widow,  two  children.  The  patient  was  sent  to  me  for  operation 
by  Dr.  Abbe,  of  New  York.  She  had  been  under  his  treatment 
for  various  syphilitic  manifestations  for  several  years,  and  for 
at  least  five  years,  to  his  knowledge,  had  suffered  from  stricture 
of  the  rectum,  which  had  been  treated  in  various  ways.  At  the 
time  of  the  operation  she  was  suffering  from  a  constant  dis- 
charge of  blood  and  mucus  from  the  anus,  and  never  had  an 
evacuation  from  the  bowels  without  previously  taking  medicine, 
which  she  did  twice  a  week  regularly.  Her  general  condition 
was  fair,  and  there  was  not  much  pain  when  she  used  the  laxa- 
tives and  kept  the  bowels  open.  The  ostium  vaginae  was  much 
deformed  by  condylomatous  growths,  which  had  caused  a  good 
deal  of  hypertrophy  of  the  labia.  The  urethra  was  ulcerated 
and  partly  destroyed,  so  that  the  little  finger  easily  entered  the 
bladder.  The  stricture  began  about  three-fourths  of  an  inch 
from  the  anus,  extended  higher  than  the  index  finger  could 
reach  through  the  vagina,  and  was  so  small  that  the  finger  could 
not  be  passed  through  it. 

The  whole  mass  of  cicatricial  tissue  was  divided  in  the 
median  line  posteriorly,  the  incision  reaching  several  inches  up 
the  bowel  and  well  above  the  disease,  and  including  all  of  the 
perinseum  between  the  anus  and  the  tip  of  the  coccyx,  which 
was  exposed  in  the  wound.  The  haemorrhage  was  free,  and 
was  controlled  by  packing  the  rectum  with  lint. 

20 


306  DISEASES    OF    THE    RECTUM    AND    ANUS. 

The  patient  did  well  in  spite  of  adverse  circumstances.  The 
bowels  moved  for  the  first  time  on  the  seventh  day  after  the 
operation.  At  the  end  of  two  weeks  she  was  having  comforta- 
ble, painless,  well-formed  passages  without  medicine,  and  with 
sufficient  control  of  the  sphincter  for  cleanliness.  Four  weeks 
after  the  operation  the  patient  was  able  to  attend  to  her  usual 
work,  and  expressed  herself  as  perfectly  satisfied  with  her  con- 
dition, which  was  better  in  every  way  than  for  j^ears  before. 

On  examining  this  patient  three  months  after  the  operation, 
I  was  surprised  to  find  a  considerable  degree  of  recontraction, 
although  the  patient  was  decidedly  more  comfortable  than  be- 
fore and  was  well  satisfied  with  the  result.  The  contraction 
was  found  to  be  due  to  a  rapid  closure  of  the  incision  through 
the  stricture  tissue,  and  this  gave  way  very  readily  to  the  pass- 
age of  the  finger,  again  opening  the  canal.  One  year  after  the 
operation  the  patient  was  still  very  comfortable,  but  obliged  to 
continue  the  use  of  bougies  to  prevent  recontraction. 

Case.   External  Proctotomy. — E.  A.  B ,  patient  operated 

upon  in  consultation  with  Dr.  Rand,  of  Newark,  N.  J.  The 
patient,  a  man,  aged  about  thirty-eight  years,  had  a  distinct 
syphilitic  history,  and  had  suffered  from  stricture  of  the  rectum 
for  ten  years,  and  from  fistula  for  two  years.  For  some  months 
past  he  had  noticed  also  a  decided  failure  in  sexual  power, 
which  he  attributed  to  the  rectal  trouble.  The  fistula  had  once 
been  cut  without  any  relief,  and  the  stricture  had  recently  be- 
come so  tight  that  he  was  afraid  of  its  complete  closure.  To 
avoid  this,  he  was  in  the  habit  of  taking  a  very  hard  bougie, 
resting  it  upon  the  floor,  and  then,  by  sitting  down  upon  the 
sharp  end  of  it,  forcing  it  into  the  bowel  by  the  weight  of  his 
body.  There  was  great  trouble  in  securing  evacuations  from 
the  bowels,  and  a  constant  muco-purulent  discharge,  with  oc- 
casional escape  of  fa3ces  involuntarily. 

On  examination,  an  exceedingly  tight  and  firm  stricture, 
which  would  allow  of  the  passage  of  nothing  larger  than  a  lead 
pencil,  was  found  just  within  the  external  sphincter.  The  fis- 
tula was  in  the  median  line  posteriorly,  and  was  a  trivial  affair, 
having  its  internal  opening  just  below  the  stricture,  and  being 
subcutaneous  for  its  entire  course.  This  was  first  divided,  and 
then  the  stricture,  which  proved,  after  it  had  been  cut  suffi- 
ciently to  admit  the  finger,  to  be  nearly  annular  in  form.  The 
bowel  was  comparatively  healthy  above. 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  307 

Eighteen  months  after  the  operation  there  had  been  no  re- 
contraction  and  the  patient  was  exceeding  well  satisfied  with 
the  result. 

Case.     External  Proctotomy  for  Cancer. — Mrs.  H ,  aged 

fifty-four,  mother  of  seven  children.  Family  history  good. 
This  case,  when  first  seen  by  me  in  consultation  with  Dr.  Prior, 
of  Connecticut,  had  been  suffering  with  cancer  for  about  two 
years,  and  had  recently  been  relieved  by  him  of  an  attack  of 
faecal  obstruction  which  was  very  nearly  fatal.  On  my  first 
examination  I  found  the  anterior  wall  of  the  rectum  fully  in- 
volved in  the  disease  as  far  up  as  the  fold  of  peritoneum.  This 
I  easily  made  out  by  vaginal  examination.  Just  within  the 
sphincter  my  finger  came  in  contact  with  the  growth,  and  the 
lumen  of  the  bowel  at  this  point  was  just  sufficient  to  engage 
the  end  of  the  index  without  allowing  it  to  pass.  The  examin- 
ation of  the  posterior  wall  of  the  bowel  was,  therefore,  unsatis- 
factory ;  but  the  idea  I  gained  was  that  the  disease  was  limited 
in  that  direction,  and  could  probably  be  removed  from  that 
point  almost  completely  without  much  danger. 

I  began  the  operation  with  this  idea  of  particular  extirpation 
in  my  mind.  The  stricture  readily  admitted  the  small  cautery- 
knife  and  was  quickly  cut  through,  but  above  it  I  came  in  con- 
tact with  a  mass  of  disease  completely  surrounding  the  bowel, 
and  forming  a  stricture  through  which  no  opening  could  be 
discovered. 

To  burn  through  this  solid  wall  of  cancerous  disease  without 
any  guide  as  to  the  direction  of  the  channel  for  the  faeces  was  a 
task  of  considerable  difficulty,  and  not  without  danger  of  open- 
ing into  the  peritoneum.  It  was,  however,  happily  accom- 
plished after  a  considerable  time,  and  the  lumen  of  the  bowel 
was  largely  restored  by  the  destruction  of  such  portions  of  the 
growth  as  were  most  easily  attacked  with  the  cautery  and  sharp 
scoop  of  Simon. 

On  the  tenth  day,  when  the  sloughs  separated,  a  free  secon- 
dary haemorrhage  occurred,  the  patient  losing  about  a  pint  of 
blood  and  fainting  twice.  This  ceased  spontaneously,  and 
when  last  heard  from  she  was  having  easy  evacuations  of  the 
bowels  and  progressing  favorably. 

In  an  analysis  of  cases  made  some  time  since,  I  found  that 
in  eighteen  cases  of  non-malignant  stricture  treated  in  this  way, 
all  the  patients  were  greatly  relieved  as  to  general  health,  or 


308  DISEASES    OF    THE    RECTUM    AND    ANUS. 

local  condition,  or  both.  In  eight,  kept  under  observation  for 
a  period  of  from  three  months  in  one  case  to  four  years  in  three 
cases,  the  cure  was  absolute,  there  being  no  return  of  the  con- 
traction, and  in  some  a  disappearance  of  all  induration.  A 
tendency  to  recon traction  is  mentioned  in  four,  due  in  two  to 
the  fact  that  all  of  the  stricture  was  not  divided. 
Brief  notes  of  some  of  these  cases  are  given  below. 

External  Proctotomy  with  the  Knife. 

1.  Panas. — Female,  aged  thirty-three.  Syphilitic  stricture, 
very  dense  and  painful ;  eight  years'  duration.  Incontinence 
for  three  months  after  operation.  Eighteen  months  later, 
described  as  completely  cured. — Gaz.  des  Hop.,  December,  1872. 

2.  Whittle. — Hard  annular  stricture,  very  close  ;  one  fis- 
tula. Operation  as  for  ordinary  fistule.  Haemorrhage  trouble- 
some and  controlled  by  thermo-cautery.  .  Three  weeks  later, 
"  general  health  completely  restored  and  local  condition  greatly 
relieved." — Lancet,  June  1,  1878. 

3.  Pan  as. — Woman,  aged  forty.  Stricture  probably  syphi- 
litic. Two  previous  operations  by  slight  internal  incision,  and 
two  attempts  at  cure  by  dilatation.  Patient  very  feeble  ;  suffer- 
ing from  abdominal  distention  ;  signs  of  approaching  occlu- 
sion ;  ovarian  tumor ;  diarrhoea  and  vomiting.  Operation 
followed  by  relief  of  pain  and  by  great  comfort  ;  no  tendency 
to  return  ;  vomiting  and  diarrhoea  continued  till  death,  some 
time  after,  from  exhaustion.  Post-mortem  examination  showed 
the  complete  success  of  the  operation,  and  the  division  in  the 
fibrous  tissue. — Gaz.  des  Hop.,  December,  1872. 

External  Proctotomy  with  the  Ecraseur,  Galvano- Cautery  or 

Thermo-  Cautery. 

1.  Tuelat. — Ano-rectal  syphiloma,  of  several  years'  dura- 
tion, with  great  thickening,  ulceration,  and  fistula?.  Operation 
(kind  not  stated)  five  years  before,  unsuccessful.  Galvano- 
cautery.  Nine  days  after  operation,  pneumonia  and  facial 
erysipelas.  Death  in  three  weeks  without  local  accident. — 
Prog.  Med.,  June  22,  1878. 

2.  VEBNEUIL.  —  Stricture  of  several  years'  duration  ;  great 
induration  and  tumefaction,  and  twenty  fistulous  tracks. 
Three  operations  :  first,  on  one-half  the  fistula? ;  second,  on  re- 


NON-MALIGNANT    STRICTURE    OF   THE    RECTUM.  309 

mainder ;  and  third,  on  the  stricture  with  ecraseur.  Four 
months  later,  "wound  healed  and  functions  of  the  rectum  en- 
tirely re-established." — Gaz.  des  Hop.,  1872,  p.  1028. 

3.  Verneuil. — Previous  syphilis  ;  great  constitutional  dis- 
turbance ;  scrotum  enlarged  to  three  times  its  natural  size  hy 
fistulous  tracks,  of  which  there  were  twelve.  Ecraseur  through 
one  of  the  fistula — others  operated  on  a  month  later.  Two 
3rears  later,  parts  had  regained  their  suppleness,  and  all  traces 
of  disease  had  disappeared. — Log.  cit. 

4.  Verneuil. — Patient  in  bad  general  condition.  Two  oper- 
ations with  ecraseur  at  six  weeks'  interval.  First,  posterior 
proctotomy  with  division  of  posterior  fistula?  ;  second,  anterior 
proctotomy  with  division  of  anterior  fistula?.  Incontinence  lasted 
only  a  few  days.  There  was  marked  tendency  to  recontraction, 
due  to  the  fact  that  the  stricture  was  so  extensive  that  the  chain 
was  not  carried  to  its  upper  limit,  and  a  distinct  zone  of  cica- 
tricial tissue  was  left. — Log.  cit. 

5.  Verneuil. — Woman,  reduced  to  last  degree  of  marasmus, 
with  hectic.  Stricture  complicated  with  much  ulceration  above 
and  below,  and  three  or  four  fistula?.  Operation  followed  by 
great  relief  of  all  symptoms.  After  several  years,  again  ex- 
amined ;  general  condition  still  good,  but  a  very  appreciable  re- 
contraction  of  a  year's  duration. — Log.  cit. 

6.  Verneuil. — Stricture  very  close  and  hard  ;  previous  dil- 
atation without  effect.  Phlegmon  existing  on  one  side,  and 
old  fistula  on  the  other.  Abscess  laid  open  and  chain  passed 
through  it  into  gut  above  stricture.  Four  years  later,  died  of 
phthisis,  having  been  entirely  free  from  symptoms  in  meantime. 
Before  death,  stricture  admitted  two  fingers  easily. — Log.  cit. 

7.  Verneuil. — Constriction  very  hard  and  close  ;  also  fis- 
tula. It  was  found  almost  impossible  to  pass  trocar  beyond 
the  contraction,  on  account  of  its  great  hardness,  and  this  was 
finally  accomplished  only  by  boring  a  track  with  a  pair  of  curved 
scissors.  The  ecraseur  required  three-quarters  of  an  hour  to 
cut  through.  Several  months  later,  general  state  very  satisfac- 
tory ;  rectal  wall  had  partly  regained  its  suppleness  ;  no  diffi- 
culty in  defecation,  but  a  still  appreciable  contraction,  due  to 
the  fibres,  which  were  too  high  up  for  the  chain. — Log.  cit. 

8.  Verneuil. — Previous  syphilis.  General  condition  bad. 
Stricture  consisted  of  a  limited  contraction  of  the  posterior  and 
upper  fibres  of  the  sphincter,  and  disappeared  on  prolonged 


310  DISEASES    OF   THE    RECTUM    AND    ANUS. 

pressure  with  the  finger.  Two  previous  operations,  one  by  in- 
ternal incision,  the  other  by  nicking  and  dilatation.  Division 
by  trocar  and  ecraseur  ;  incontinence  for  a  few  days  ;  after 
three  weeks,  passages  natural  and  all  symptoms  relieved. 
Three  years  after,  again  examined,  and  found  suffering  from 
rectal  syphiloma  developed  since  operation,  together  with  ter- 
tiary eruptions. — Loc.  cit.  [History  completed  by  Tison  in 
These  de  Paris.'] 

9.  Verneuil. — Previous  syphilis  ;  stricture  annular  ;  much 
constitutional  disturbance,  great  pain,  diarrhoea,  colic,  and  dis- 
charge of  pus.  Operation  of  internal  proctotomy  with  thermo- 
cautery, followed  by  phlegmon.  Abscess  opened  and  external 
operation"  done  with  thermo-cautery  through  abscess  cavity. 
One  month  later,  relief  of  all  symptoms ;  return  of  suppleness 
in  parts;  stricture  admitted  two  fingers  easily;  tendency  to 
recontraction  in  posterior  part  of  rectum  ;  anterior  part  healthy. 
— Tison,  TTtese  de  Paris. 

10.  Verneuil. — Rectal  syphiloma  ;  anaemia  and  loss  of 
flesh ;  great  tenesmus.  Thermo-cautery.  Incontinence  for 
three  weeks.  Reported  completely  cured  after  three  months. — 
Tison. 

11.  Verneuil. — Stricture,  probably  inflammatory,  with  sev- 
eral fistulse.  Thermo-cautery.  Incontinence  for  three  weeks. 
After  five  weeks,  appetite  and  strength  returned  ;  passages  easy 
and  painless. — Tison. 

12.  Gosselin. — Syphilitic.  Forced  dilatation  three  years 
before.  General  condition  very  bad  from  excesses  of  all  kinds ; 
passages  very  frequent  and  painful.  Thermo-cautery,  followed 
by  temporary  relief.  Four  months  later,  condition  same  as  be- 
fore, with  signs  of  commencing  phthisis. — Tison. 

13.  Tillaux. — Valvular  stricture,  posterior,  with  ulceration  ; 
anterior  portion  healthy ;  several  fistulffi.  Galvano-cautery. 
Three  j^ears  later,  complete  cure,  and  no  return. — Tison. 

14.  Tillaux.— Old  stricture,  probably  syphilitic,  with  gen- 
eral cachexia — so  great  as  to  resemble  that  of  cancer.  Ecraseur. 
Four  years  later,  remained  completely  cured. — Tison. 

15.  Tillaux.— Probably  syphilitic  ;  previous  rupture  of 
perinpeum  ;  enormous  dilatation  of  anus;  incontinence  of  fluid 
faeces  ;  general  condition  exceedingly  bad  ;  signs  of  occlusion  ; 
operation  undertaken  without  hope  of  cure,  but  to  relieve  worst 
symptoms.     Galvano-cautery,  from  without  inward,  with  cau- 


NON-MALIGNANT    STRICTURE    OF   THE    RECTUM.  311 

tery  knife.     Life  prolonged  five  months,  with  freedom  from 
suffering. 

16.  Verneuil. — Dysenteric  contraction  high  up,  twelve  cen- 
timetres from  anus.  Under  mistaken  diagnosis  of  spasmodic 
stricture  of  the  sphincter,  that  muscle  was  divided  with  the 
cautery.  Entire  relief  from  pain,  but  continued  symptoms  of 
retention. — Tison. 

17.  Labbe. — Probably  syphilitic;  much  pain;  abscesses; 
fistulae.  Division  with  gal vano- cautery,  followed  by  considera- 
ble haemorrhage  and  tampon.  After  a  time,  slight  return  of 
contraction  at  margin  of  anus,  the  rest  of  gut  remaining  supple. 
Second  operation  by  Verneuil  with  thermo-cautery,  followed  in 
the  course  of  six  months  by  prolapse  of  the  rectum,  which  was 
cured  by  cauterization  of  the  posterior  edge  of  the  anus.  Con- 
siderable amelioration  of  suffering. — Tison,  quoted  from  Cerou, 
These  de  Paris. 

18.  Verneuil. — Syphiloma  of  long  standing  ;  great  anaemia  ; 
intolerable  pain  ;  constant  purulent  discharge  ;  previous  dilata- 
tion unsuccessful.  Ecraseur.  followed  by  dilatation.  Four 
years  later,  absolute  cure.  JN"o  induration ;  sphincter  acting 
well. — Tison,  These  de  Paris. 

19.  Fochier. — Stricture  of  many  years'  standing.  Patient 
feeble  and  emaciated ;  great  gastro-intestinal  derangement ; 
two  fistulae.  The  constriction  was  first  divided  with  a  bistoury 
cache  to  admit  the  finger,  and  operation  completed  with  ecra- 
seur. Control  of  sphincter  after  the  first  few  days.  Left  hos- 
pital ten  days  after  the  operation,  with  appetite  and  digestion 
good,  and  general  health  much  improved,  having  soft  passages 
of  the  size  of  the  finger. — Lyon  Med.,  February  20,  1876. 

Cancers. 

1.  Verneuil. — Cancer.  Ecraseur,  followed  by  immediate  re- 
lief ;  decrease  in  induration  ;  recovery  of  appetite  and  strength. 
Death  from  subsequent  operation  of  excision. — Oaz.  des  Hop., 
1872. 

2.  Verneuil. — Cancer  reaching  beyond  point  of  finger ; 
sphincter  continually  in  contraction,  and  violent  pain  caused 
by  slightest  touch  ;  attempts  at  dilatation  followed  by  phlegmon 
and  fistula  ;  constant  pain  and  tenesmus,  with  bloody  passages  ; 
insomnia ;  rapidly  approaching  fatal  termination.  The  opera- 
tion consisted  merely  in  dividing  the  sphincter  with  ecraseur 


312  DISEASES    OF   THE    RECTUM    AND    ANUS. 

without  touching  the  cancer,  and  the  relief  was  so  great  that 
the  patient  left  hospital  believing  himself  cured. — Gaz.  des  Hop., 
November,  1872. 

3.  Verneuil. — Cancer,  with  all  the  usual  symptoms,  and 
approaching  occlusion,  ficraseur ;  death  on  the  ninth  day 
from  peritonitis. — Gaz.  des  Hop.,  November,  1872. 

4.  Verneuil. — Cancerous  stricture  high  up,  and  very  close  ; 
constant  suffering  from  discharges  of  gas  and  pus.  Ecraseur 
passed  as  high  as  possible,  but  not  high  enough  to  divide  upper 
portion.  Considerable  relief  ;  cessation  of  pain  ;  passages  easy 
for  several  months.  Death  finally  from  progress  of  disease. — 
Gaz.  Hebdom.,  March  27,  1874,  p.  196. 

5.  Verneuil. — Epithelioma  involving  right  half  of  rectum, 
and  reaching  too  high  for  extirpation  ;  ulceration ;  loss  of  flesh 
and  strength  ;  great  pain  on  defecation  ;  retention.  Sphincter 
divided  with  chain  on  left  side  in  such  a  way  as  not  to  involve 
the  cancer.  One  year  later,  freedom  from  pain  ;  general  state 
good  ;  incontinence  following  operation  disappeared  ;  difficulty 
in  passage  of  solids  overcome  by  seltzer  ;  gradual  advancement 
of  cachexia. — Gaz.  Hebdom.,  March  27,  1874,  p.  196. 

6.  Verneuil. — Cancer  high  up,  involving  prostate  and  vesi- 
cular seminales.  Continued  diarrhoea  and  incontinence,  and  bad 
general  condition.  A  double  posterior  external  operation  was 
done  with  the  chain,  and  the  portion  included  between  the  two 
incisions  cut  away,  with  the  idea  of  relieving  pain  and  retention 
and  opening  a  j>assage  for  the  subsequent  application  of  eschar- 
otics  to  the  cancer.  Operation  followed  by  immediate  relief  of 
worst  symptoms. — Gaz.  Hebdom.,  March  27,  1874. 

7.  Nelaton. — Operation  done  with  bistoury.  Relief  con- 
tinued till  death,  eighteen  months  after,  from  extension  of  ma- 
lignant disease  to  the  pelvis. — Panas  :  Gaz.  des  Hop.,  1872,  p. 
1149. 

8.  Fociiier. — Cancer  of  posterior  part  of  rectum,  reaching 
to  height  of  ten  centimetres.  Great  pain  and  tenesmus  ;  foetid 
and  bloody  discharge  ;  loss  of  sleep.  Complete  division  with 
ecraseur.  Left  hospital  ten  days  after,  believing  himself  cured. 
After  two  months,  had  no  more  pain  and  no  incontinence,  ex- 
cept when  suffering  with  diarrhoea.  Had  two  regular  passages 
daily,  and  complained  only  of  not  regaining  his  strength.  In 
t)ii-  case,  the  section  extended  to  the  unusual  height  of  twelve 
centimetres  from  the  anus. — Lyon,  Med.,  February  20,  1876. 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  313 

I  have  performed  this  operation  in  various  other  cases  be- 
sides those  of  my  own  detailed  above,  and  have  every  reason  to 
be  satisfied  with  its  results.  In  malignant  or  non-malignant 
stricture  and  ulceration,  I  have  never  seen  it  fail  to  give  imme- 
diate relief  to  suffering,  and,  as  a  means  of  relieving  the  pain  of 
the  disease,  I  believe  it  to  be  fully  equal  to  colotomy.  It  also 
fulfils  the  other  great  indication  for  colotomy,  the  overcoming 
and  prevention  of  obstruction. 

Too  much  must  not  be  expected  of  the  operation,  however. 
I  have  seen  several  cases,  one  in  my  own  practice,  and  several 
where  I  have  advised  the  operation  in  consultation  with  others, 
which  have  led  to  disappointment  for  this  very  reason.  An  old 
stricture  of  the  rectum  with  extensive  ulceration  is  a  well-nigh 
incurable  disease.  Proctotomy  may  be  relied  upon  with  cer- 
tainty to  relieve  the  pain  and  prevent  fsecal  obstruction  even  in 
the  worst  cases,  and  in  more  favorable  ones  it  may  effect  a  prac- 
tical cure  by  opening  the  canal,  causing  a  diminution  in  the  in- 
duration, and  allowing  the  ulceration  to  heal ;  but  it  will  not 
cure  them  all.  Nothing  at  present  known  to  surgery  will.  A  rec- 
tum which  has  once  been  diseased  to  tins  extent  is  never  again 
a  healthy  one,  though  it  may  be  made  a  very  comfortable  one. 

Another  point  which  must  not  be  overlooked  is  that  after 
proctotomy,  as  after  colotomy,  there  is  still  a  diseased  rectum 
which  must  be  treated  by  every  possible  means,  and  that  the 
incision  may  be  only  the  first  step  in  the  cure.  The  stricture  is 
easier  to  overcome  than  the  ulceration  which  accompanies  it.  In 
one  of  the  cases  given  above  I  succeeded  ultimately  by  long  and 
patient  effort  in  curing  that  also,  but  it  cannot  be  done  in  every 
case.  In  many  of  these  cases  the  ulceration  must  be  treated  as 
ulceration  with  the  same  results,  both  good  and  bad,  as  usually 
attend  the  treatment  of  that  most  painful,  obstinate,  and  often 
incurable  condition.  But  the  chances  of  curing  it,  and  at  all 
events  of  relieving  it,  are  infinitely  better  after  the  operation 
than  before. 

It  is  understood  that  I  do  not  advocate  the  operation  in  cases 
of  disease  high  up  in  the  bowel,  though  it  may  be  safely  done 
at  a  considerable  distance  from  the  anus,  and  where  an  incision 
involving  the  anterior  wall  would  be  unjustifiable,  for  the  ana- 
tomical reason  that  the  peritoneum  extends  so  much  lower  in 
front  than  behind.  For  other  literature  upon  this  subject,  the 
reader  is  referred  to  the  bibliography  given  below. 


314  DISEASES    OF    THE    BECTUM    AND    ANUS. 


Bibliography. 

Panas  :  Du  traiternent  des  retrecissements  du  rectum  par  la  rectotomic  ex- 
terne,  Gaz.  des  Hop.,  December,  1872,  p.  1148. 

Mttron,  A.  :  Des  retrecissements  de  Texti-emite  inferieure  du  rectum,  et  de 
leur  guCrison  par  la  rectotomie  lineaire.     Gaz.  Med.  de  Paris,  January  4,  1873. 

Fochier,  A.  :  Sur  l'application  de  la  rectotomie  lineaire  aux  retrecissements 
tres-etendus  du  rectum.     Lyon  Medicale,  February  20,  1876. 

Pinguet  :  Des  retrecissements  du  rectum  ;  appreciation  des  diverses  metho- 
des  therapeutiques.     These  de  Paris,  1873,  No.  17. 

Tison  :  Nouvelles  considerations  sur  la  rectotomie  lineaire.  These  de  Paris, 
1877. 

Tuegis:  Foreign  Body  in  Bectum.  Bull,  de  la  Soc.  de  Chir.,  tomeiv.,  No. 
10,  1878,  p.  789. 

Cekou  :  These  de  Paris,  1875,  No.  390. 

Whitehead,  W.  B.  :  Case  of  Fibrous  Stricture  of  the  Bectum  Believed  by  In- 
cisions and  Elastic  Pressure,  with  Bemarks.  American  Journal  of  the  Medical 
Sciences,  January,  1871. 

WhittjjE,  G.  :  Stricture  of  the  Bectum  Divided  by  the  Knife.  Lancet,  June 
1,  1879,  p.  788. 

Lente,  F.  D. :  Beport  of  a  Case  of  Non-Malignant  Stricture  of  the  Bectum, 
and  Bemarks  on  the  Surgical  Treatment  of  this  Disease.  American  Journal  of 
the  Medical  Sciences,  July,  1873. 

Beane,  F.  D.  :  Case  of  Specific  Stricture  of  the  Bectum ;  Antero-Posterior 
Linear  Bectotomy  ;  Becovery  ;  Bemarks  on  the  Operation.  American  Journal 
of  the  Medical  Sciences,  April,  1878. 

Discussion  sur  les  retrecissements  du  rectum.— Bull,  de  la  Soc.  de  Chir., 
p.  83.     Paris,  1873. 

Verneuil,  et  al. :  Bectotomie  et  colotomie  (Soc.  de  Chir.,  Paris).  Prog. 
Med.,  January  7,  1882. 

Excision. — The  operation  of  excision,  which  is  generally  ap- 
plied only  to  cancerous  strictures,  and  which  will  be  fully  de- 
scribed under  that  head,  has  also  been  applied  to  simple  strict- 
ures ;  and,  though  I  have  never  done  it  myself,  I  have  seen  a 
few  cases  which  seemed  particularly  adapted  to  it.  One  such 
case  is  reported  by  Dr.  Lowson '  in  which  the  result  was  com- 
paratively good,  though  no  better  than  that  obtained  by  proc- 
totomy. 

The  operation  performed  by  him  consisted  in  dividing  the 
external  sphincter  posteriorly,  so  as  to  arrive  at  the  stricture, 
pulling  it  down  through  this  wound  when  possible,  dividing  the 
bowel  above  and  below  it,  dissecting  it  out  from  its  attachments, 

1  Caae  of  Stricture  of  the  Rectum,  treated  by  Excision  of  the  Stricture.  Lancet, 
April  12,  1870. 


NON-MALIGNANT    STRICTURE    OF    THE    RECTUM.  315 

and  uniting  the  two  ends  of  the  bowel  by  sutures.  In  this  case 
there  was  considerable  difficulty  in  the  subsequent  union  of  the 
parts,  and  after  healing  had  occurred  there  was  considerable 
contraction,  but  the  condition  of  the  patient  was  greatly  im- 
proved. 

Colotomy. — This  is  the  last  resort  of  surgery  in  dealing  with 
ulceration  or  stricture  of  the  rectum.  In  ulceration  it  may  be 
a  curative  measure ;  in  stricture  it  is  only  palliative,  and  it 
should  therefore  not  be  undertaken  until  other  measures  have 
failed.  It  is  intended  to  fulfil  two  important  indications,  the  re- 
lief of  pain  and  preventing  or  overcoming  obstruction,  and  we 
have  already  seen  how  both  of  these  may  be  met  in  many  cases 
by  other  means  which,  even  when  only  partially  successful,  are 
much  preferable. 

When  none  of  the  methods  already  pointed  out  serve  to 
assuage  the  suffering,  and  when  it  is  probable  that  the  suffering 
is  not  due  to  an  irritable  sphincter  muscle,  or  to  pressure  on 
neighboring  nerves  from  the  mass  of  the  deposit,  cancerous  or 
otherwise  (in  which  latter  case  colotomy  cannot  be  expected  to 
afford  relief),  and  when  none  of  the  means  already  described  for 
preventing  or  overcoming  obstruction  can  be  applied,  colotomy 
may  be  resorted  to.  There  is,  however,  but  one  class  of  cases 
in  which  obstruction  may  not  be  overcome  by  attacking  the 
stricture  itself,  instead  of  the  bowel  above  it,  and  that  is  where 
the  stricture  is  too  high  to  be  safely  reached  by  the  knife,  and 
where,  even  then,  dilatation  is  too  painful  or  too  dangerous  to 
be  admissible. 

Judged  by  these  rules,  colotomy  would  be  limited  to  a  small 
proportion  of  cases.  It  would  be  tried  after  division  of  the 
sphincter  and  of  the  stricture  had  each  failed  to  give  relief  in 
disease  near  the  anus  ;  and  practically  wrould  be  limited  to  dis- 
ease high  up  in  the  bowel.  Such  restrictions  as  these  would 
greatly  limit  the  number  of  operations,  especially  in  the  United 
States,  and  I  am  not  sure  that  this  might  not  be  done  with  ad- 
vantage. We  seldom  see  in  the  reports  of  this  operation  in  cur- 
rent literature  any  other  reason  given  for  its  performance  than 
the  mere  existence  of  obstructive  or  painful  disease  ;  and  yet  I 
doubt  if  the  mere  presence  of  a  stricture  of  the  rectum,  malig- 
nant or  benign,  is  a  justifiable  reason  for  the  performance  of 
this  repulsive  and  serious  operation  any  more  than  a  stricture 
of  the  urethra  justifies  the  operation  of  cystotomy.     It  has  yet 


310  DISEASES    OF    THE    RECTUM    AND    ANUS. 

to  be  proved  that  colotomy  delays  cancerous  growth,  though  it 
certainly  prolongs  life  by  diminishing  pain  and  overcoming  ob- 
struction. But  the  relief  to  the  pain  may  be  and  often  is  only 
partial,  for  a  small  amount  of  faeces  which  has  passed  the  arti- 
ficial anus  may  cause  as  much  suffering  and  tenesmus  as  the 
natural  quantity. 

In  almost  direct  proportion  as  the  operations  of  proctotomy 
and  of  partial  or  complete  excision  of  strictures  have  become 
popularized  and  their  advantages  in  suitable  cases  have  become 
manifest,  the  operation  of  colotomy  has  been  limited  and  the 
natural  objections  to  it,  both  by  patient  and  surgeon,  have  been 
allowed  more  weight  in  influencing  the  treatment.  Especially 
is  this  the  case  in  France,  the  birthplace  of  the  operation,  and 
in  Germany,  while  England,  as  represented  by  Allingham,  is 
plainly  following  in  the  same  course.  In  this  country  alone 
does  colotomy  still  hold  its  sway — partly  for  the  reason  that  its 
substitutes  have  never  been  so  thoroughly  tried  here  as  on  the 
other  side  of  the  water. 

It  would  be  easy  at  the  present  time  to  collect  a  much  larger 
table  of  cases  of  this  operation  than  was  accessible  to  Mason 
when  he  published  his  paper  on  this  subject,  but  I  do  not 
know  that  anything  would  be  added  to  our  general  knowledge 
of  the  subject  by  such  a  labor.  Allingham  had  operated  at  the 
time  of  his  last  edition  twenty  seven  times.  His  best  result  was 
obtained  in  a  man  with  a  scirrhous  growth  filling  up  the  pelvis, 
in  whom  life  was  prolonged  four  and  a  half  years  after  the 
operation.  Another  case,  a  woman,  lived  nineteen  months, 
twelve  of  them  in  wonderful  comfort.  Only  three  of  his  pa- 
tients died  within  a  fortnight  of  the  operation,  one  from  phleg- 
monous eiysipelas,  another  from  exhaustion ;  and  the  third,  in 
nine  days,  in  whom  there  was  complete  obstruction  at  the  time 
of  the  operation,  and  in  whom  paracentesis  abdominis  was  per- 
formed immediately  after  the  colotomy,  acute  pleurisy  being 
the  immediate  cause  of  death.  Curling  has  performed  the  oper- 
ation eighteen  times  with  seven  fatal  results  ;  two  from  chloro- 
form, one  from  already  existing  peritonitis,  another  from  peri- 
tonitis arising  independently  of  the  operation,  but  immediately 
succeeding  it,  one  from  pyaemia,  and  two  from  exhaustion,  one 
on  the  sixth,  and  the  other  on  the  twelfth  day.  Bryant  records 
fifteen  operations  of  his  own,  four  for  vesicointestinal  fistula  ; 
two  for  pelvic  tumor ;  and  nine  for  stricture,   cancerous  and 


NON-MALIGNANT    STRICTUEE    OF    THE    RECTUM.  317 

otherwise.  Of  these  latter,  one  lived  eighteen  months  in  com- 
fort, dying  at  last  supposably  of  cancer  of  the  liver  ;  two  lived 
two  and  four  months  respectively  ;  one  lived  thirteen  days,  and 
two  three  days  ;  in  these  cases  the  operation  having  been  under- 
taken too  late  to  prolong  life.  One  died  of  peritonitis  due  to 
the  operation,  and  three  were  alive  at  periods  varying  from  one 
to  three  years. 

Bulteau  '  has  collected  one  hundred  and  forty -two  cases  of 
lumbar  colotomy  from  the  statistics  of  Doliger,  Mason,  Haw- 
kins, and  Heath.  Of  these  ninety-two  recovered  and  fifty  died. 
These  figures  are  about  the  same  as  those  reached  by  D'Erck- 
elens.2 

These  figures  show  as  well  as  would  a  more  elaborate  collec- 
tion of  cases,  the  general  results  of  the  operation  itself,  the 
dangers  which  attend  it,  and  especially  the  danger  of  postpon- 
ing its  performance  till  the  patient  is  at  the  point  of  death. 
These  patients  sometimes  sink  with  unexpected  rapidity  at  the 
end,  and  when  seemingly  no  worse  than  for  weeks  before,  are 
often  very  near  death.  In  my  own  experience  I  have  had  a 
patient  die  in  the  night  upon  whom  I  intended  to  operate  in  the 
morning. 

Although  an  artificial  anus  is  justly  regarded  as  being  only 
a  substitute  for  death  itself,  and  although  many  patients  will 
deliberately  choose  the  latter  to  the  dangers  and  results  of  the 
former,  it  is  astonishing  how  comfortable  a  patient  may  be 
with  one  where  the  retention  of  faeces  is  good.  Bridge's  case,3 
in  which  the  prostitute  followed  her  customary  avocation  after 
its  performance,  is  certainly  an  exceptionally  favorable  one,  but 
it  illustrates  what  may  be  done.  Still  we  have  Allingham's 4 
testimony  that  "this  operation,  though  doubtless  it  may  pro- 
long life,  should  not  be  resorted  to  without  due  consideration, 
because  one  cannot  fail  to  see  in  many  cases  the  remedy  proves 
a  most  objectionable  one  ;  an  opening  in  the  left  loin  through 
which  the  faeces  escape  is  very  harassing,  and  nothing  but  a 
great  desire  to  live  or  the  fear  of  immediate  death  would  lead 
me  to  submit  to  such  a  proceeding.  I  presume  after  years  the 
patients  get  used  to  the  discomforts  and  loathsomeness  of  their 

1  De  l'occlusion  intestinale  au  point  du  vue  du  diagnostic  et  du  traitement.  These 
de  Paris,  1878. 

2  Arch,  fur  Klin.  Chirurg.,  vol.  xxiii.,  1  Heft,  1878. 

3  Loc.  cit.  4  Loc.  cit. ,  p.  253. 


318  DISEASES    OF   THE    RECTUM    AND    ANUS. 

condition.  My  patients  who  have  lived  long  seem  to  have  had 
some  pleasure  in  life  ;  indeed,  two  women  were  married  after 
the  operation  ;  but  with  all  that  I  entertain  repugnance  to  the 
operation  greater  than  I  formerly  used,  and  latterly  have  mostly 
performed  it  as  a  last  resource  or  for  total  obstruction." 

The  operation  has  already  been  described.  A  free  discharge 
of  faeces  may  follow  the  opening  of  the  bowel,  or  there  may  be 
only  a  slight  escape  of  fluid.  It  is  better  for  the  patient  that 
the  evacuation  should  be  postponed  till  the  edges  of  the  wound 
have  become  agglutinated,  as  in  this  way  the  danger  of  extrava- 
sation is  diminished.  Morphine  should  be  given  hypodermic- 
ally  to  keep  the  bowels  as  quiet  as  possible  till  cicatrization  is 
complete.  Only  the  simplest  dressings  and  perfect  cleanliness 
are  necessary  in  the  way  of  local  treatment.  The  sutures  may 
be  left  in  till  they  commence  to  cause  suppuration.  If  the 
bowels  are  slow  to  empty  themselves,  an  enema  may  be  admin- 
istered, or  a  scoop  used  through  the  new  opening,  and  a  purga- 
tive may  be  given  by  the  mouth.  No  change  is  necessary  in  the 
ordinary  diet  after  the  second  day.  The  patient  should  be  kept 
in  bed  for  two  or  three  weeks  till  cicatrization  is  complete,  and 
then  a  pad  must  be  arranged  to  cover  the  new  anus  and  prevent 
leakage  of  faeces  and  prolapse  of  the  mucous  membrane.  Bry- 
ant says  some  of  his  patients  have  found  great  comfort  from  the 
use  of  an  india-rubber  ball  with  one  of  its  sides  cut  away  suffi- 
ciently to  cover  the  new  opening.  It  holds  any  little  faeces 
which  may  come  away,  besides  preventing  the  escape  of  flatus 
and  serving  as  a  pad. 

Annoying  prolapse  is  not  as  apt  to  occur  with  the  oblique  in- 
cision as  with  the  old  vertical  one  ;  nevertheless,  it  may  be  ex- 
pected in  some  degree,  and  the  patient  should  be  taught  to 
exercise  the  greatest  regularity  in  relieving  the  bowels  early  in 
the  morning. 

Should  faeces  pass  by  the  artificial  opening,  as  they  are  apt 
to  do,  they  must  be  removed  by  enemata,  for  a  very  small  quan- 
tity will  cause  great  pain  and  a  constant  demand  for  their  re- 
moval. 

It  will  at  once  be  seen  that  the  treatment  of  a  stricture  high 
up  in  the  rectum  or  in  the  sigmoid  flexure  must  be  conducted 
on  entirely  different  principles  from  one  within  reach  of  the 
finger.  In  the  latter  case,  the  disease  itself  may  be  directly 
attacked  with  the  bougie  or  the  knife  ;  in  the  former,  both  are 


NON-MALIGNANT    STRICTURE    OP   THE    RECTUM.  319 

nearly  out  of  the  question,  and  the  surgeon  is  in  reality  limited 
to  attempts  at  warding  off  the  natural  effects  of  the  malady ;  in 
other  words,  to  preventing  the  occurrence  of  intestinal  obstruc- 
tion, and  forming  an  artificial  outlet  for  the  contents  of  the 
bowel  when  obstruction  is  threatened.  The  medicinal  means  of 
preventing  obstruction,  and  of  overcoming  it  when  actually  im- 
pending, have  already  been  referred  to  in  the  chapter  on  pro- 
lapse and  invagination.  In  cases  of  cancerous  disease,  atten- 
tion must  be  given  to  cleanliness  as  well  after  as  before  the 
operation,  and  this  is  best  secured  by  frequent  injections  of 
an  unirritating  disinfectant,  as  the  permanganate  of  potash  or 
chloral.  In  cases  of  non-malignant  ulceration,  the  diseased  sur- 
face may  be  treated  after  the  operation  as  before. 


CHAPTER  XII. 

CANCER. 

General  Characters  of  Malignant  as  Distinguished  from  Benign  Growths. — Malignant, 
Semi-Malignant,  and  Benign  Adenoma. — Encephaloid. — Colloid. — Melanotic  Can- 
cer.— Osteoid  Cancer. — Age  at  which  Cancer  occurs. — Symptoms. — Diagnosis. — 
Treatment. — Excision  :  History  and  Results  of  Operation. — Conclusions  Regarding 
Excision. — Modes  of  Performing  the  Operation. — Excision  of  Cancer  of  the  Sig- 
moid Flexure. — Palliative  Treatment. 

In  a  general  way  it  is  undoubtedly  true  that  new  growths  in  the 
rectum,  when  benign,  increase  slowly,  tend  to  grow  away  from 
the  wall  of  the  bowel,  to  form  pedicles  for  themselves,  and  to 
project  into  the  calibre  of  the  canal,  to  remain  movable,  and 
not  to  involve  surrounding  parts  ;  while  with  cancerous  forma- 
tions the  tendency  is  just  the  opposite.  In  this  way  the  diag- 
nosis between  a  benign  polyp  and  a  cancerous  nodule  in  the 
wall  of  the  rectum  is  generally  easy. 

But  there  is  a  class  of  tumors  which  occupies  the  border  line 
between  the  benign  and  the  malignant,  in  which  the  diagnosis, 
either  clinically  or  with  the  microscope,  may  be  difficult  and 
even  impossible.  In  fact,  recent  careful  study  of  these  rectal 
tumors  goes  far  to  break  down  the  lines  between  the  varieties 
which  are  usually  drawn,  and  Cripps,1  who  has  done  such  care- 
ful and  valuable  work  in  this  department,  is  inclined  to  group 
nearly  all  of  them  under  the  single  head  of  adenoma,  holding 
that  all  are  primarily  affections  of  the  glandular  element.  The 
true  nature  of  the  growths  may  perhaps  best  be  gleaned  from  a 
comparison  of  Fig.  83  with  Fig.  72,  the  latter  being  a  benign 
polypus,  and  the  former  a  malignant  growth,  but  both  being- 
adenomata. 

According  to  Cripps  the  names  malignant,  semi-malignant, 
and  simple  adenoid  will  cover  both  the  benign  and  cancerous 

1  Cancer  of  the  Rectum,  London,  1880.  Also,  Adenoid  Disease  of  the  Rectum. 
Trans.  Path.  Soc.  of  London,  1881. 


CANCER.  321 

growths  of  this  part  of  the  body,  except  possibly  the  form  of 
colloid.  Generally,  but  not  always,  it  is  possible  to  distinguish 
between  them  both  clinically  and  microscopically. 

After  speaking  of  the  innocent  growth,  which  is  soft,  has  a 
fairly  marked  pedicle,  and  projects  into  the  cavity  of  the  bowel, 
he  says:  "In  the  more  malignant  varieties,  the«new  growth 
frequently  spreads  as  a  thin  layer  between  the  muscular  and 
mucous  coats.  In  this  form  it  often  occupies  several  square 
inches  of  the  bowel,  while  its  thickness  does  not  exceed  a 
quarter  of  an  inch.  At  first  the  mucous  membrane  lies  intact 
over  such  a  layer,  but  eventually  it  gives  way  by  ulceration. 
This  ulceration  sometimes  begins  at  more  than  one  point,  so 
that  the  mucous  membrane  becomes  honeycombed,  and  portions 
of  the  subjacent  growth  may  even  sprout  through  it.     The  de- 


Fig.  83. — Cancer  of  the  Rectum — Malignant  Adenoma.    (Stimson.) 

structive  process  not  only  destroys  the  mucous  membrane  over 
the  surface  of  the  growth,  but  after  a  while  the  new  growth  is 
itself  destroyed  by  ulceration.  While  destruction  is  proceeding 
toward  the  centre,  the  growth  is  advancing  toward  the  circum- 
ference. In  this  way  a  crater-like  mass  of  disease  is  produced, 
the  centre  of  which  consists  of  dense  fibrous  tissue  belonging  to 
the  muscular  coat  of  the  bowel,  which  appears  for  long  to  resist 
the  ulcerative  process.  The  margin  of  the  crater  consists  of  the 
mucous  membrane  of  the  bowel,  heaped  up  by  the  extending 
growth  beneath  it,  tucking  it  over  in  such  a  manner  as  to  overlap 
the  healthy  membrane.  The  border  is  at  times  so  irregular  as 
to  represent  a  series  of  nodules  rather  than  a  continuous  line." 
Stimson '  has  also  made  a  careful  study  of  these  growths.    He 

'  A  Contribution  to  the  Study  of  Cancer  of  the  Rectum.     Archives  of  Medicine, 
August,  1879. 

21 


322  DISEASES    OF    THE    RECTUM    AND    ANUS. 

says  :  "  If  it  is  admitted  that  cancer  of  the  rectum  is  essentially 
a  glandular  or  epithelial  affection,  one  having  its  origin  in  the 
mucous  membrane,  the  borders  of  the  growth,  as  being  the 
freshest,  most  recent  portions,  must  be  examined,  as  in  car- 
cinoma of  other  organs,  for  evidences  of  primary  changes  and 
mode  of  development.  These  changes  consist  of  hypertrophy 
of  the  mucosa  by  hypertrophy  and  hyperplasia  of  its  epithelial 
elements,  together  with  an  abundant  development  of  embryonal 
connective  tissue  between  the  tubules.  They  are  the  same  as 
those  found  in  a  variety  of  neoplasm  of  recognized  benign  char- 
acter known  as  polyp  of  the  rectum  or  polypoid  adenoma.  The 
formation  of  a  pedunculated  growth  with  a  tendency  to  isola- 
tion in  the  one  case,  and  of  a  flat  growth  with  a  tendency  to 
spread  laterally  and  into  the  underlying  tissue  in  the  other, 
may  be  explained  partly  by  mechanical  causes  and  partly  by 
the  degree  of  intensity  of  the  changes  in  the  submucous  connec- 
tive tissue.  If  the  primary  change  occupies  a  limited  area  upon 
a  natural  fold  of  the  mucous  membrane,  and  if  the  muscularis 
mucosae  remains  unbroken  until  the  young  embryonal  cells 
produced  below  it,  in  consequence  of  the  neighboring  irritation, 
have  had  time  to  develop  into  adult  fibrous  tissue,  the  natural 
retraction  of  this  new  tissue  narrows  the  base  of  the  fold,  giving 
it  at  once  a  polypoid  form  and  opposing  by  its  greater  density 
a  stronger  barrier  to  the  extension  of  the  epithelial  formation  in 
this  direction.  The  pedicle  once  formed,  the  neoplasm  increases 
in  the  direction  open  to  it,  that  is,  into  the  lumen  of  the  canal 
in  all  its  diameters,  and  the  dragging  to  which  it  is  subjected 
by  the  constantly  recurring  passage  of  the  fseces  lengthens  its 
pedicle  and  tends  toward  its  final  separation. 

"On  the  other  hand,  if  a  broader  area  is  occupied  by  the 
primary  change,  or  if  the  processes  are  more  intense  and  rapid, 
the  pedunculation  is  absent  or  less  perfect,  and  the  epithelial 
growths  of  the  mucosa  break  through  immediately,  or  after  an 
interval  spent  in  overcoming  the  greater  resistance  offered  by 
the  partial  pedunculation,  into  the  submucous  tissue.  Once 
established  in  that  region  the  spread  of  the  disease  is  easy,  and 
its  ultimate  generalization  a  question  only  of  time. 

"The  second  and  final  barrier  to  generalization  is  presented 
by  the  muscular  coat  of  the  intestine,  but  it  is  a  barrier  in  which 
are  many  gaps,  large  ones  along  the  lines  of  the  vessels,  and  in- 
numerable small  ones  in  the  line  meshes  of  connective  tissue 


caistcer.  323 

which  separate  the  muscular  bundles  and  are  continuous  with 
the  submucous  tissue  on  one  side  and  the  para-rectal  tissue  on 
the  other.  Here,  too,  the  intensity  of  the  process  materially 
affects  the  rapidity  of  its  extension,  for  if  the  proliferating  con- 
nective tissue,  which  is  most  easily  implicated  while  it  is  in  the 
formative  stage,  is  allowed  time  to  reach  its  full  development, 
to  become  fibrous,  it  forms,  as  it  were,  a  second  line  of  defence 
capable  of  offering  a  certain  resistance  after  the  first  line  has 
been  carried.7' 

With  a  full  appreciation  of  the  importance  of  the  conclu- 
sions which  Cripps  has  reached,  it  may  still  be  well,  in  a  work 
of  this  kind,  to  call  attention  to  some  of  the  clinical  characters 
of  some  of  the  different  forms  of  malignant  disease  as  found  in 
this  part  of  the  body. 

Of  all  the  varieties  of  true  cancer,  the  one  most  frequently 
met  with  is  epithelioma,  and  this  presents  itself,  here  as  else- 
where in  the  body,  under  two  forms  distinguishable  with  the 
microscope  and  clinically.  The  first  (cancroid,  lobulated  epi- 
thelioma) contains  the  characteristic  onion-like  nests  of  squam- 
ous epithelium,  and  is  the  same  form  so  commonly  seen  in  the 
lip,  though  rarely  about  the  anas.  It  has  its  point  of  origin  at 
the  anus,  and  not  within  the  rectum,  and  begins  as  a  hard,  dry, 
warty  nodule.  It  is  slow  in  progress,  covered  at  first  with  firm 
epidermis,  and  only  begins  to  ulcerate  late  in  its  course.  It 
seldom  spreads  far  up  the  rectum,  but  tends  rather  to  involve 
the  integument,  which  it  may  destroy  to  an  extent  similar  to 
that  sometimes  seen  in  the  same  variety  of  disease  about  the 
face.  In  the  other  variety  (cylindrical  epithelioma)  the  cells 
are  columnar,  and  the  growth  resembles  in  minute  structure  the 
mucous  membrane  from  which  it  springs.  This  variety,  on  the 
contrary,  chooses  the  rectum  proper  for  its  development,  and  is 
found  above  the  internal  sphincter.  It  is  easily  distinguished 
from  the  former,  but  not  so  easily  from  a  scirrhus  which  has  be- 
gun to  ulcerate.  It  is  softer  than  the  other,  more  vascular,  and 
therefore  more  prone  to  bleed  and  undergo  extensive  degenera- 
tion and  ulceration,  and  it  rapidly  infiltrates  surrounding  tis- 
sues. Early  in  its  course  it  is  movable  on  the  subjacent  tissues, 
but  it  is  seldom  seen  by  the  surgeon  at  this  stage.  At  a  later 
period  it  presents  itself  as  a  soft,  friable  mass  seated  on  a  hard, 
infiltrated  base  ;  ulcerated  in  spots,  the  edges  of  the  ulcers  being 
hard  and  raised.    At  this  stage  the  growth  will  yield  on  press- 


324  DISEASES    OF    THE    KECTUM   AND    ANUS. 

lire  the  well-known  cancer  jnice  containing  cells  and  nuclei,  and 
it  may  be  difficult  to  distinguish  it  from  a  tumor- which  began 
in  the  submucous  tissue  as  a  hard  mass,  and  subsequently 
underwent  degeneration. 

Next  to  epithelioma,  scirrhus,  or  hard  cancer,  is  the  variety 
most  frequently  met  with  in  the  rectum.  It  arises,  not  like  epi- 
thelioma, in  the  mucous  membrane,  but  in  the  submucous  con- 
nective tissue ;  therefore,  in  the  early  stages  of  its  growth  the 
membrane  is  found  normal  and  movable  over  the  hard  mass  be- 
neath. When  cut  into  it  shows  the  characteristic,  raw-potato- 
like hardness  of  scirrhus,  and  there  is  no  distinct  line  of  demar- 
cation between  it  and  the  adjacent  tissues.  From  the  original 
tumor  are  often  seen,  and  sometimes  felt,  hard  fibrous  bands 
spreading  out  in  various  directions,  generally  longitudinally  in 
the  bowel — the  processes  or  claws  from  which  cancer  takes  its 
name.  These  tumors  may  soften  down  in  parts  and  slough  or 
ulcerate  away.  When  ulceration  has  begun,  a  cavity  with  an 
irregular  outline  is  formed  in  the  midst  of  the  hard  cancer  tis- 
sue, from  which  issues  a  foetid  discharge  mixed  with  more  or  less 
blood  and  pus.  Although  a  large  part  of  the  growth  may  die 
in  this  way  and  be  discharged,  the  steady  increase  in  the  disease 
is  not  checked.  Indeed,  the  growth  often  seems  to  be  most 
rapid  in  the  bed  of  the  part  which  has  been  destroyed. 

This  form  of  cancer  is  said  to  be  most  apt  to  show  itself  first 
on  the  anterior  wall  of  the  rectum,  near  the  prostate,1  and  "  to 
increase  most  on  the  side  of  the  chief  arterial  supply,  and  in 
that  toward  which,  by  lymphatics  and  veins,  its  constituent 
fluids  most  easily  filter."  2  It  spreads  by  infiltrating  all  the 
adjacent  parts,  eventually  involving  all  the  coats  of  the  bowel, 
and  extending  both  in  surface  and  thickness  till,  instead  of 
apjjearing  as  a  hard,  movable  spot  under  the  mucous  membrane, 
it  involves  a  great  part  or  the  whole  of  the  circumference  of  the 
rectum,  inclosing  it  in  a  dense,  contracting  sheath.  The  hard- 
ness and  contractility  of  this  form  of  disease  are  the  chief 
clinical  facts  upon  which  a  diagnosis  rests  ;  and  yet,  leaving  out 
of  consideration  the  history  of  the  case,  it  will  often  be  impossi- 
ble to  distinguish  between  the  gross  appearances  of  scirrhus  and 
those  of  simple  fibrous  stricture.  I  have  now  under  treatment, 
at  the  Infirmary  for  Diseases  of  the  Rectum,  a  case  of  stricture 


Allingham,  Molliore.  2  Moore.     See  Bryant's  Surgery. 


CANCER.  325 

which  I  believe  to  be  dysenteric  in  origin,  in  which  the  extent 
of  the  disease  is  fully  as  great  as  in  any  hard  cancer  I  have  ever 
met  with,  and  yet  which  has  been  eighteen  years  in  developing. 

Enceplialoid  has  its  primary  seat  in  the  glandular  tissue  of 
the  mucous  membrane.  It  is  inclosed  in  a  capsule  of  connect- 
ive tissue,  from  the  internal  surface  of  which  spring  trabecule 
which  divide  the  mass  into  lobules.  On  section,  it  may  be 
comparatively  firm  or  nearly  fluid,  and  almost  white  or  stained 
red  with  blood.  It  is  often  very  vascular  ;  large  vessels  may 
sometimes  be  seen  on  its  surface,  and  large  blood  extravasations 
may  be  found  in  its  interior.  The  name  fungus  nematodes  has 
been  applied  to  a  variety  of  this  disease  in  which,  after  the  cap- 
sule has  burst,  the  mass  has  protruded.  The  material  compos- 
ing it  may  resemble  brain  tissue  (from  which  it  is  named),  or  it 
may  be  more  spongy  and  shreddy,  like  placenta.  On  squeez- 
ing a  section  of  the  tumor  a  large  amount  of  juice  may  be  ob- 
tained, and  this,  when  thrown  into  a  vessel  of  water,  is  uni- 
formly diffused  through  it,  giving  it  a  milky  hue.  This  is  given 
by  Paget  as  an  exceedingly  valuable  rough  test  of  the  nature 
of  the  growth.  These  cancers  are  rapid  in  their  increase,  and 
may  attain  an  immense  size,  fairly  filling  the  pelvis.  They 
quickly  affect  the  neighboring  lymphatics,  and,  when  enucle- 
ated, speedily  recur.  The  results  of  removal  are,  however, 
particularly  favorable  for  a  short  time,  as  shown  by  the  imme- 
diate improvement  in  the  general  condition  of  the  patient,  and 
the  disappearance  of  the  cancerous  cachexia.  The  extreme  soft- 
ness of  the  tumor,  and  the  deceptive  sense  of  fluctuation  im- 
parted to  the  finger,  may  cause  a  mistake  in  diagnosis,  which 
may  be  avoided  by  the  use  of  the  aspirator,  or  even  the  hypo- 
dermic syringe.  When  the  fluid  thus  obtained  is  examined 
under  the  microscope,  it  will  be  found  to  contain  cells  and 
nuclei,  with  more  or  less  blood. 

In  colloid  cancer  (alveolar  cancer)  the  structure  is  essentially 
the  same  as  in  the  last  variety,  except  that  the  alveolar  meshes 
are  filled  with  a  jelly-like  material,  which  in  its  most  natural 
state  is  glistening,  translucent,  and  pale  yellow.  This  variety 
of  cancer  has  its  origin  in  the  follicles  of  Lieberkiihn,  or  the 
crypts  which  surround  the  rectum.  It  is  not  very  rare  in  this 
part,  and  appears  in  the.  shape  of  large,  lobulated,  fungus-like 
tumors,  which  are  soft  and  easily  broken  down.  Under  the 
microscope,  the  mucous  contents  of  the  alveoli  will  be  seen  to 


326  DISEASES    OF    THE    EECTUM    AND    ANUS. 

contain  cells  of  various  forms,  the  most  characteristic  being 
large,  round,  and  flat,  with  a  nucleus  and  concentric  laminae. 
The  growth  rapidly  infiltrates  the  surrounding  tissues,  and 
secondary  deposits  will  often  be  found  in  the  neighborhood  of 
the  original  mass,  the  whole  tending  to  undergo  cystic  degener- 
ation. The  malignancy  of  these  tumors  varies  in  degree,  some 
of  them  being  comparatively  benign ;  they  do  not  always  recur 
after  removal,  nor  do  they  readily  infect  the  lymphatics  and 
viscera,  being  in  this  respect  about  on  a  par  with  epithelioma. 
The  term  colloid  is  used  without  much  exactness,  being  applied 
to  almost  any  growth  which  consists  in  part  of  large,  cellular 
spaces  filled  with  glue-like  material.  The  following  description 
of  a  case  illustrates  very  perfectly  the  general  characteristics  of 
colloid : 

Case. — "The  patient  was  an  old  woman,  and  the  case  was 
peculiar,  in  that  the  colloid  material  was  contained  in  cysts  of 
various  sizes,  pressed  firmly  one  against  the  other,  so  that  the 
disease  might  be  called  multiple  cystic  colloid  degeneration. 
The  anus  was  surrounded  with  a  large  number  of  tumors  of 
unequal  size,  of  which  several,  larger  than  the  rest,  were  sur- 
mounted by  smaller  ones  in  such  a  way  that  the  anus  occupied 
the  bottom  of  an  extremely  deep  infundibulum.  Two  super- 
ficial ulcerations  were  to  be  seen  at  the  margin  of  the  anus.  The 
finger  recognized  at  a  short  distance  above  the  anus  an  ulcera- 
tion in  the  form  of  a  zone,  which  was  deep,  had  destroyed  all 
the  thickness  of  the  rectum  in  a  part  of  its  circumference,  and 
communicated  with  fistulous  tracks,  which  penetrated  into  the 
substance  of  the  diseased  skin  adjacent  to  the  anus. 

"The  degeneration,  which  had  given  the  rectum  an  enor- 
mous thickness,  ceased  abruptly  nine  or  ten  centimetres  from  the 
anus.  Immediately  above,  the  rectum  presented  considerable 
hypertrophy  in  the  muscular  layer.  This  affection,  which  had 
all  the  characters  of  colloid  degeneration,  presented  an  arrange- 
ment in  its  upper  two-thirds  which  I  had  never  before  met  with, 
and  which  I  will  try  and  describe.  Let  one  imagine  a  number 
of  acephalocysts  of  unequal  size  (some  of  them  as  large  as 
pigeons'  eggs)  squeezed  firmly  one  against  the  other,  and  held 
in  a  fibrous  network,  and  one  will  have  an  exact  idea  of  the 
change.  Only  these  were  not  acephalocysts.  The  covering  of 
each  cyst  was  fibrous,  very  thin,  and  yet  very  strong  ;  the  mat- 
ter contained  in  them  exactly  resembled  currant  jelly,  on  the 


CANCER.  327 

surface  of  which  had  been  deposited  a  cretaceous  matter  exactly 
similar  to  that  which  sometimes  covers  the  excrement  of  birds. 
This  cretaceous  matter  contained  calcareous  concretions.  In 
the  centre  of  the  jelly-like  substance  two  or  three  blood-vessels 
were  to  be  seen,  similar  to  those  which  form  in  a  hen's  egg — 
vessels  without  walls,  ending  in  an  enlargement  of  one  ex- 
tremity. 

"  The  fibrous  network  in  the  midst  of  which  these  cysts  were 
inclosed  was  evidently  made  up  of  the  transformed  coats  of  the 
rectum.  I  could  recognize  the  longitudinal  fibres  of  the  rectum. 
There  was  also  adipose  tissue,  an  evident  proof  that  the  de- 
generation had  not  only  invaded  the  rectum,  but  had  developed 
at  the  expense  of  the  adipose  tissue  of  the  pelvis. 

"  The  lower  third  of  the  rectum  presented  no  sign  of  a  cyst, 
but  an  areolar  tissue,  with  fibrous  meshes,  which  occupied  all 
the  circumference  of  the  anus  ;  this  tissue  was  filled  like  a 
sponge  with  colloid  matter,  which  could  easily  be  pressed  out, 
and  the  tissue  itself  was  approaching  erosion  or  ulceration. 
The  areolar  and  gelatiniform  degeneration  appeared  to  me  to 
penetrate  into  the  thickness  of  the  skin  of  the  anal  region  ; 
while  an  extremely  thin,  almost  epidermic,  pellicle  had  resisted 
and  covered  the  swellings  on  its  surface.  In  the  vicinity  of  the 
circular  ulceration  of  the  rectum,  the  colloid  matter  had  not 
undergone  degeneration,  only  it  was  permeated  by  an  increased 
number  of  blood-vessels.  Behind  the  rectum  was  a  colloid  al- 
veolar mass,  all  the  areolae  of  which  contained  blood-vessels. 
This  mass  had  evidently  been  formed  at  the  expense  of  the  cir- 
cum-rectal  adipose  tissue."  ' 

Cruveilhier  draws  this  distinction  between  colloid  and  en- 
cephaloid.  The  colloid  degeneration  is  not  susceptible,  as  is  the 
encephaloid,  of  inflammatory  action  producing  gangrene  ;  more- 
over, if  the  sanguineous  centres  are  not  absolutely  foreign  to 
it,  it  is  certain  that  they  are  incomparably  rarer  in  colloid  than 
in  the  cancerous  degeneration,  properly  so  called,  where  effu- 
sions of  blood  are  so  often  met  with — apoplectic  centres  some- 
times so  large  as  to  conceal  the  true  nature  of  the  morbid 
tissue. 

Colloid  alveolar  degeneration  shows  only  one  mode  of  de- 
struction— by  encroachment  in  successive  layers ;  this  encroach- 

1  Cruveilhier  :  Traite  d'Anatomie  Path.  Gen.,  t.  v.,  p.  67. 


328  DISEASES    OF    THE    RECTUM    AND    ANUS. 

merit,  sometimes  rapid  when  it  occurs  in  the  alimentary  canal, 
permits  of  the  re-establishment  of  the  flow  of  faeces,  tempo- 
rarily interrupted  by  the  undefined  and  often  very  rapid  in- 
crease in  the  degenerated  parts  ;  so  that,  to  the  gravest  signs  of 
faecal  retention,  there  sometimes  succeeds  a  more  or  less  rapid 
separation,  with  and  without  diarrhoea.1 

Melanotic  carcinoma,  or  black  cancer,  is  by  some  classed 
among  the  true  cancers,  and  by  others  among  the  sarcomata. 
It  belongs  to  the  class  of  soft  or  medullary  cancers,  and  its  dis- 
tinguishing feature  is  the  development  of  pigment.  What- 
ever may  be  said  of  the  microscopic  characters  of  melanoma,  it 
is  clinically  a  very  malignant  growth,  running  a  very  rapid 
course,  and  very  likely  to  become  generalized.  Its  clinical  his- 
tory, as  relates  to  the  rectum,  is  to  be  studied  from  ten  cases 
only,  which  have  been  given  in  full  in  an  exhaustive  study  by 
Nepveu,  read  before  the  Societe  de  Chirurgie  (1880).2  The  cases 
are  reported  by  the  following  observers:  Schilling,3  Kopp,4 
Moore,5  Maier,6  Virchow,7  Ashton,8  Gross,0  Meunier,10  G-ussen- 
bauer,11  and  Nepveu.12 

From  the  six  of  these  cases  which  are  reported  with  an  ap- 
proach to  completeness,  several  facts  of  interest  are  to  be  gath- 
ered. The  age  of  all  of  the  patients  was  advanced,  ranging  be- 
tween forty-five  and  sixty-four  years.  Five  were  in  men,  one 
only  in  a  woman.  In  the  microscopic  examinations  which  were 
made  in  five  of  the  cases,  the  tumor  is  in  every  case  described 
as  a  sarcoma.  There  is  nothing  in  the  symptomatology  to  dis- 
tinguish this  form  of  disease  from  others,  except  that  in  one 
case  the  stools  were  colored  black  from  mixture  with  the  pig- 
ment— a  point  which  might  aid  in  diagnosis  were  the  tumor  so 
high  up  as  to  be  out  of  sight.    In  rectal  examinations  it  was 

1  Cruveilhier  :   Traite  d'Anatomie  Path.  Gen.,  t.  v.,  p.  69. 
5  Memoires  de  Chirurgie,  Paris,  1880. 

3  Mentioned  by  Eiselt,  obs.  v.,  Prag.  Viertelj.,  Bd.  70  u.  76. 

4  Denkwurdigkeiten  in  der  iirztlichen  Praxis,  Bd.  iv.,  Frankfort,  1838,  pp.  305-313. 

5  Medical  Times,  March,  1857. 

6  Berichte  iiber  die  Verhandlungen  der   Naturforschenden   Gesellschaft  zu  Frei- 
burg, 185s,  No.  30,  p.  516. 

1  Pathologie  des  Tumeurs,  Paris,  1867,  t.  ii.,  p.  281,  note. 

8  Ashton,  T.  J.:  Prolapsus,  Fistula  in  Ano,  etc.,  3d  edition,  London,  1870,  p.  162. 
•  System  of  Surgery,  Philadelphia,  1872,  vol.  ii.,  p.  589. 
,0  Bull,  de  la  Soc.  Anat.  de  Paris,  1875,  p.  792. 

11  Ueber  die  Pigmentbildung  in  melanotischen  Sarcomen  und  einfachen  Melanomen 
dor  Haut.     Virchow's  Arch.  f.  path.  Anat.  u.  Phys.,  lxiii. ,  1875.  )2  Op.  cit. 


CANCER.  329 

also  noticed  that  the  finger  was  colored  in  the  same  way.  The 
location  of  the  disease  was  once  in  the  sigmoid  flexure,  twice  in 
the  rectum  above  the  sphincter,  and  four  times  at  the  anus. 
The  size  of  the  growth  was  generally  considerable,  surrounding 
the  bowel  and  projecting  into  its  cavity  ;  sometimes  it  was  firm 
enough  to  cause  tight  stricture,  at  others  ulcerated  and  broken 
down  in  parts.  The  course  of  the  disease  is  marked  by  second- 
ary deposits  in  the  adjacent  glands  or  in  the  viscera,  while  the 
original  growth  may  spread  in  neighboring  organs,  and  by  ulcer- 
ation cause  a  foul  discharge  mixed  with  blood  and  pigment. 
To  these  may  be  added  the  usual  signs  of  incontinence  and  ob- 
struction. The  duration  of  the  disease  in  no  case  exceeded 
three  years,  but  it  was  generally  fatal  in  a  much  shorter  time. 
The  diagnosis  is  easy  if  the  growth  can  be  seen,  and  is  some- 
times assisted  by  the  secondary  black  deposits.  In  four  cases 
the  tumor  was  removed,  but  in  none  was  the  return  long  de- 
layed. 

Osteoid  Cancer. — Either  a  sarcoma  or  a  carcinoma  in  any 
part  of  the  body  may  become  ossified,  and  hence  pathologists 
speak  of  osteo.-sarcoma  and  osteo-carcinoma.  It  is  rare  that 
such  a  formation  is  found  in  any  structure  except  bone  or  peri- 
osteum ;  and  there  seems  to  be  but  one  case  on  record  of  bone- 
cancer  of  the  rectum,  which,  because  of  its  great  rarity,  I  will 
quote  in  part : 

Case.— The  preparation  was  removed  from  the  body  of  a 
lady,  aged  about  fifty-four,  who  died  January  18,  1869,  under 
the  care  of  Mr.  Collambeli,  of  Lambeth.  The  history  of  the 
case  pointed  to  the  existence  of  disease  in  the  rectum  for  about 
twenty  years  (during  which  time  she  had  occasionally  com- 
plained of  pain,  irregularity  of  the  bowels,  and  a  discharge  of 
blood  and  mucus).  .  .  .  The  specimen  includes  the  whole 
pelvic  viscera.  The  rectum  is  laid  open  posteriorly,  but  rather 
on  the  right  side,  and  shows  a  cancerous  mass  projecting  into 
its  interior  at  a  distance  of  about  four  or  five  inches  from  the 
anus.  The  principal  mass,  of  about  the  size  of  a  walnut,  is  sit- 
uated directly  at  the  back,  and  occupies  nearly  the  whole  cali- 
bre of  the  rectum,  but  the  disease  involves,  more  or  less,  the 
entire  circumference  of  the  intestine  upon  a  level  rather  above 
the  larger  mass.  A  small  opening,  large  enough  to  admit  a 
goose-quill,  is  found  in  the  sigmoid  flexure,  about  twelve  inches 
above  the  cancerous  growth,  and  communicates  with  a  circum- 


330  DISEASES    OF   THE    RECTUM    AND    ANUS. 

scribed  abscess  cavity  within  the  peritoneum,  above  the  pelvic 
viscera  and  behind  the  pubes,  and  this  again  communicates 
with  the  rectum  immediately  below  the  obstruction.  At  the 
time  of  the  post-mortem  this  peritoneal  abscess  contained  very 
little  fluid,  but  what  there  was  was  pus  discolored  with  faecal 
matter.  There  is  also  a  large,  foul,  burrowing  abscess,  situated 
in  the  submucous  tissues,  almost  completely  surrounding  the 
rectum  at  the  seat  of  the  disease,  communicating  freely  with  its 
cavity  and  directly  continuous  with  the  intra-peritoneal  abscess. 

When  first  laid  open,  the  surface  of  the  cancer  generally 
presented  a  nodulated,  red  appearance,  but  the  larger  or  pos- 
terior mass  was  roughened  in  its  lower  half  by  numerous  sharp 
spicules  of  bone  which  projected  from  its  surface.  The  cut  sur- 
face showed  the  growth  involving  the  thickened  muscular  coat 
as  a  hard,  contracting  mass,  and  from  its  base  firm  fibrous 
bands  ramified  into  the  neighboring  fat,  just  as  from  the  base 
of  an  ordinary  scirrhous  tumor.  That  portion  which  projected 
into  the  cavity  of  the  rectum  was  softer,  and  its  lower  part  was 
occupied  throughout  by  numerous  spicules  of  true  bone.  On 
the  surface,  the  softer  structures  having  sloughed  away,  the 
bony  constituents  were  exposed.  The  growth  did  not  extend 
to  the  sacrum,  which  was  perfectly  healthy,  and  the  other  bones 
of  the  pelvis  were  also  free  from  disease. 

The  other  viscera  were  examined  and  appeared  healthy. 
The  lymphatic  glands  were  not  carefully  examined,  but  in  the 
parts  which  were  removed  there  was  no  glandular  enlargement 
to  be  found.  The  ulceration  in  the  sigmoid  flexure  seemed  to 
be  of  a  simple  character ;  there  was  no  evidence  of  malignant 
deposit  elsewhere  than  in  the  obstructed  portion  of  the  rectum. 

On  examining  the  growth  in  the  rectum  it  was  found  to  be 
firm  in  the  deeper  parts,  where  it  involved  mucous  and  sub- 
mucous tissues,  but  nearest  to  the  surface,  where  the  spicules 
of  bone  were  evident,  it  had  the  appearance  and  character,  to 
the  naked  eye,  of  a  fibro-fatty  structure.  In  the  deepest  parts, 
however,  where  it  was  firmest,  it  had  not  any  very  great  hard- 
ness. The  parts  involved  in  the  ossification  lay  exposed  in  the 
rectum,  and  seemed,  from  their  shreddy,  softened  appearance, 
to  have  been  recently  sloughing.  Upon  section,  a  quantity  of 
juice  was  readily  obtained,  and  showed  under  the  microscope 
an  immense  number  of  free  nuclei  and  cells  of  all  shapes  and  of 
variable  sizes,  though  the  greater  number  were  elongated  or 


CANCER.  331 

oval,  and  about  half  the  size  of  the  columnar  epithelium  of  the 
neighborhood.  There  was  a  large  quantity  of  molecular  matter 
and  oil,  and  the  nuclei  were  indistinct.  The  solid  portion  of 
the  growth  was  composed  of  cellular  and  muscular  structures 
imbedded  in  a  granular  matrix.  Bands  and  fibres,  composed 
almost  altogether  of  nuclei,  ramified  in  the  growth,  and  could 
be  traced  as  continuous  with  the  osseous  portions.  It  appeared 
that  the  nuclei  became  darker,  granular,  and  harder  in  outline 
as  the  examination  was  carried  toward  the  ossified  parts  ;  the 
intervening  matrix  became  more  fibrous,  and  the  processes  of 
bone  branched  out  into  this.  The  bony  spicules  contained  num- 
erous lacunae,  whose  size  was  about  that  of  the  ordinary  nuclei 
of  the  growth.  They  were  of  various  forms,  generally  branch- 
ing, and  were  arranged  with  no  regularity,  but  in  the  manner 
usually  found  in  adventitious  bony  deposits  in  tumors.  The 
matrix  was  granular. 

The  interest  of  this  case  lies  chiefly  in  the  fact  of  bone  being 
found  ramifying  through  parts  of  the  structure  ;  and  that  this 
bone  was  the  result  of  ossification  of  the  scirrhous  growth  seems 
evident  from  the  manner  in  which  it  could  be  traced  under  the 
microscope.  That  it  was  not  an  original  formation  apart  from 
the  scirrhus  must  be  admitted,  for  its  histological  characters 
show  its  definite  relation  to  the  elements  of  the  tumor,  the 
lacunae  replacing  the  nuclei,  and  the  rest  of  the  bone  occupying 
the  place  of  the  intervening  matrix.  And  a  primary  bone  tumor 
in  this  position  is  difficult  to  imagine.  The  occurrence  of  true 
bony  deposit  in  medullary  tumors  is  not  altogether  infrequent, 
but  then  it  is  found  in  the  deeper  parts,  and  is  almost  always 
in  connection  with  some  bone.  In  scirrhous  growths,  however, 
I  do  not  find  any  mention  of  ossification  occurring,  except 
where  starting  from  bone.  I  have  no  history  of  any  case  of  any 
kind  of  tumor  of  the  rectum  in  which  bone  formed  an  element 
of  a  primary  growth.1 

These  are  the  rarer  forms  of  cancerous  disease  in  the  rectum 
and  their  recognition  presents  little  difficulty.  Most  malignant 
growths  are  included  under  Cripps'  classification  of  adenoma  or 
under  the  older  terms  of  epithelioma  and  scirrhus.  Hecker2 
found  twenty-one  cases  of  epithelioma  in  thirty-four  cases  of 
cancer.     Cripps  says:   "I  have  failed  to  discover"  (in  the  rec- 

1  Wagstaffe  :  Trans,  of  the  Path.  Soc.  of  London,  vol.  xx.,  p.  176. 

2  Schmidt's  Jahrbucher,  1870. 


332  DISEASES    OF    THE    RECTUM    AND    ANUS. 

turn)  "any  growths  or  tumors  consisting  entirely  of  the  char- 
acteristic structure  which  pathologists  designate  as  scirrhus  or 
medullary  cancers,  or  as  belonging  to  the  various  varieties  of 
sarcoma.  Considering  the  eminence  of  many  careful  observers 
who  have  applied  such  names  to  these  growths,  it  would  be 
quite  unjustifiable  to  assume  that  such  distinctive  structures 
never  form  the  entire  bulk  of  the  tumor  ;  but  I  feel  bound  to 
state  that  with,  perhaps,  a  more  than  average  opportunity  of 
examining  such  growths  from  the  rectum,  I  have  been  unable 
mj^self  to  discover  tumors  composed  entirely  of  the  distinctive 
features  appertaining  to  these  diseases." 

Cancer  of  the  rectum,  like  cancer  elsewhere  in  the  body, 
generally  occurs  in  middle  life  or  old  age.  There  are,  however, 
some  interesting  exceptions  to  this  rule. '  Allingham  '  reports  a 
case  of  encephaloid  in  a  boy  of  seventeen,  under  his  own  care, 
and  another  (variety  of  cancer  not  stated)  under  the  care  of  Mr. 
Gowland,  in  a  boy  not  thirteen  ;  Mayo  2  speaks  of  one  at  the 
age  of  twelve,  and  Godin 3  of  one  at  fifteen  years  ;  Quain  4  quotes 
one,  reported  by  Busk,  at  sixteen;  and  Despres 6  reports  an 
epithelioma  in  a  child  of  six.  After  the  age  of  twenty  the  cases 
increase  rapidly  in  number.  With  regard  to  the  relative  fre- 
quency in  the  sexes,  different  statements  will  be  found  in  the 
works  of  different  writers,  according  to  the  experience  each  has 
had,  and  considerable  reasoning  has  been  indulged  in  to  explain 
why  the  disease  should  be  more  common  in  the  one  sex  than 
in  the  other.  In  a  collection  of  one  hundred  and  seven  cases,  I 
have  found  fifty  in  males  and  fifty-seven  in  females. 

The  locality  in  which  the  disease  first  appears  varies. 
Quain8  sa}^s  :  "I  have  most  frequently  met  with  the  lower 
margin  of  the  deposit  at  the  distance  of  from  two  to  three  inches 
above  the  orifice  of  the  bowel.  The  part  between  that  just  in- 
dicated and  the  anus  is  next  in  order  of  frequency  as  the  seat 
of  the  disease,  and  to  this  succeeds  the  lower  end  of  the  colon." 
This  perhaps  expresses  the  facts  of  the  case  as  well  as  they  could 
'be  stated  in  a  few  words,  f  The  upper  limit  of  the  rectum,  where 
it  joins  the  sigmoid  flexure,  is  a  common  site  of  the  disease,  and 

1  Diseases  of  the  Rectum,  London,  1809,  p.  265. 

-  Injuries  and  Diseases  of  the  Rectum,  London,  1833,  p.  188. 

3  Molliere  :  Trait'  des  Maladies  du  Rectum  etde  l'Anus,  Paris,  1877,  p.  580. 

4  Proc.  of  the  Path.  Soc.  of  London,  1846-47. 

■  Gaz.  des.  Hop.,  November  2,  1880.  '  Op.  cit. 


CANCER.  333 

here  it  runs  a  more  rapid  course  than  elsewhere,  and  is  more 
apt  to  be  suddenly  fatal  on  account  of  the  increased  liability  to 
obstruction  which  the  anatomical  condition  favors. 

The  symptoms  of  cancer  of  the  rectum  may  be  classified  as 
follows  :  pain  ;  those  due  to  contraction,  to  ulceration,  to  inva- 
sion of  neighboring  parts  ;  and,  lastly,  the  generalization  of  the 
disease  and  the  cachexia. 

A  cancer  of  the  rectum  may,  and  often  does,  begin  so  insidi- 
ously that  its  existence  is  not  suspected  by  the  patient  till  it 
has  made  irreparable  progress.  This  will  be  the  case  particu- 
larly when  the  disease  is  well  up  in  the  bowel  beyond  the  reach 
of  the  sphincters.  The  slight  sensitiveness  of  the  mucous 
membrane  of  the  rectum  proper  which  permits  the  existence  of 
extensive  ulceration,  and  the  application  of  escharotics  and 
the  performance  of  surgical  operations  without  pain  has  been 
already  referred  to.  On  the  other  hand,  cancer  of  the  rectum 
is  usually  attended  with  great  pain,  and  the  suffering  in  itself 
may  be  made  of  great  assistance  in  diagnosis,  as  in  the  follow- 
ing case. 

Case.  Cancer  Jiigli  up  in  the  Rectum. — The  patient,  a 
gentleman  slightly  over  fifty,  was  sent  to  me  by  his  family 
physician,  as  a  case  of  internal  haemorrhoids.  He  was  a  man 
of  good  habits,  had  never  had  venereal  disease,  and  was  in  good 
flesh.  He  gave  a  history  of  dysentery  some  years  since,  but  upon 
what  authority  the  diagnosis  rested  I  do  not  know.  For  several 
months  before  consulting  me  he  had  been  troubled  with  what 
he  supposed  to  be  dyspepsia,  pain  in  the  bowels,  loins,  and 
more  recently  in  the  spermatic  cords  and  inguinal  regions. 
With  this  he  had  been  having  three  or  more  slimy  and  bloody 
passages  daily.  At  the  time  of  his  visit  he  complained  of  but 
one  thing  which  he  considered  of  any  importance,  a  steady, 
wearing  pain  in  the  lower  bowel,  sufficient  to  keep  him  awake 
at  night,  and  to  unfit  him  for  work  during  the  day. 

A  most  careful  examination  was  entirely  negative.  A  full- 
sized  bougie  was  passed  its  whole  length  without  meeting  any 
obstruction. 

The  history  may  be  much  condensed.  The  pain  never  left 
him  except  when  under  the  influence  of  opium,  though  the 
bloody  passages  soon  yielded  to  treatment.  Emaciation  soon 
began  to  show  itself  and  steadily  increased.  Six  months  after 
his  first  visit,  the  diagnosis  of  cancer  which  I  then  made  be- 


334  DISEASES    OF   THE    IiECTUM    AND    ANUS. 

came  only  too  evident  from  his  personal  appearance,  and  the 
mass  could  be  distinctly  felt  in  the  left  iliac  fossa  through  the 
abdominal  wall. 

The  presence  of  a  steady,  severe  pain,  and  the  absence  of 
anything  else  except  bloody  passages  and  rapid  emaciation  may 
seem  but  slight  grounds  for  the  diagnosis  of  a  fatal  disease,  and 
so  they  are,  but  they  are  sometimes  enough.  The  strongest  point 
in  the  case  was  the  absence  of  stricture  or  of  any  of  the  ordinary 
painful  affections  of  the  rectum.  The  patient  was  also  an  ex- 
ceedingly intelligent  man  (which  assisted  greatly  in  reaching  a 
conclusion),  and  he  described  his  sufferings  in  no  uncertain 
terms,  although  rather  inclined  to  make  light  of  them. 

In  a  case  recently  seen  with  Dr.  Templeton,  of  North 
Carolina,  the  history  was  very  similar,  but  the  diagnosis  was 
dysentery  and  not  cancer.  In  his  patient  there  was  also  pain 
and  bloody  discharge  with  emaciation  ;  but  the  history  covered 
several  years,  the  pain  was  of  an  intermittent  character,  and  the 
disease  could  be  felt  just  at  the  limit  of  digital  examination. 
There  was  no  distinct  tumor,  though  there  was  thickening  of 
the  rectal  wall,  and  this  absence  of  distinct  new  growth  after 
so  long  a  period  of  disease  decided  us  in  the  diagnosis  of 
dysentery  rather  than  cancer. 

Attention  has  been  called  to  the  point  in  diagnosis  that  the 
existence  of  pain  or  cramp  in  the  lower  extremity  in  cancer  of 
the  rectum  is  a  bad  sign,  suggesting  a  direct  encroachment  upon 
some  of  the  neighboring  nerves,  either  by  implication  and  press- 
ure of  the  glands,  or  by  direct  extension  of  the  original  disease.1 
In  the  later  stages  of  cancer  the  pain  is  often  the  most  impor- 
tant symptom  to  be  met  by  treatment.  It  may  then  be  due  to 
the  irritation  of  faeces  upon  an  ulcerated  surface,  to  the  involve- 
ment of  the  anus  in  the  ulceration,  or  to  direct  pressure  on  ad- 
jacent parts,  and  each  of  these  is  to  be  met  by  a  different  and 
appropriate  treatment. 

The  symptoms  directly  referable  to  contraction  of  the  bowel 
are  often  slight,  and  differ  in  no  way  from  those  caused  by  the 
simple,  fibrous  stricture  of  the  same  part.  It  is  often  astonish- 
ing to  the  surgeon  to  meet  with  an  advanced  case  of  scirrhus  in 
which  iIm'  calibre  of  the  bowel  is  so  nearly  occluded  as  scarcely 
to  permit  the  passage  of  the  end  of  the  finger,  and  yet  in  which 

1  Hilton  :  Rest  aDd  Pain,  p.  1G3. 


CANCER.  335 

the  patient  lias  never  had  sufficient  uneasiness  to  call  for  a  direct 
rectal  examination. 

The  haemorrhage  from  an  ulcerated  rectum  in  cancerous 
disease  is  seldom  profuse  enough  to  be  dangerous,  though  by 
frequent  repetition  it  may  become  an  important  factor  in  the 
ultimately  fatal  result. 

Above  the  contraction  there  often  develops  an  ulceration 
which  is  not  to  be  confounded  with  the  breaking  down  of  the 
cancer  itself.  When  the  cancer  itself  once  begins  to  break 
down  and  ulcerate,  its  extension  is  limited  by  no  tissue  of  the 
body.  The  bladder  may  be  opened  and  a  permanent  fistula  re- 
sult, in  which  case  the  passage  is  generally  from  that  viscus 
into  the  rectum  ;  but  the  opposite  may  be  the  case — and  the 
pain  caused  by  the  entrance  of  fseces  into  the  bladder  and  their 
discharge  through  the  urethra  is  one  of  the  best  of  all  the  indi- 
cations for  colotomy.  The  prostate  and  seminal  vesicles  in  the 
male  and  the  recto- vaginal  septum  in  the  female  may  each  be 
destroyed  ;  in  fact,  any  part  near  the  disease  may  be  implicated. 
Smith1  has  recorded  a  case  in  which  the  disease  opened  into 
the  hip-joint,  and  Molliere2  another  in  which  it  invaded  the  soft 
parts  in  the  loin. 

There  are  two  sets  of  lymphatics  which  may  be  involved  in 
malignant  disease  of  the  rectum,  one  coming  from  the  anus  and 
going  to  the  glands  in  the  groin  ;  and  one  coming  from  the  rec- 
tum proper  and  going  to  the  glands  in  the  hollow  of  the  sacrum 
and  lumbar  region.  The  proper  place,  therefore,  to  feel  for 
glandular  involvement  in  disease  within  the  sphincter  is  along 
the  spine,  deep  in  the  pelvis — a  simple  point  which  may  decide 
the  surgeon  for  or  against  operative  interference.  This  impli- 
cation of  the  lymphatics  is  sometimes  shown  by  pressure  effects 
at  points  quite  remote  from  the  original  disease,  as  in  the  fol- 
lowing case  from  my  own  case-book. 

Case. — J.  B ,  aged  sixty,  has  always  been  strong  and  well 

until  within  a  few  weeks  past,  when  he  has  been  troubled  with 
obstinate  constipation.  All  he  desires  now  is  some  "pills"  to 
move  his  bowels.  On  closer  questioning,  he  refers  casually  to 
the  fact  that  he  has  considerable  pain  in  the  right  thigh,  and 
some  swelling  in  the  right  leg  and  foot,  but  "nothing  to  speak 
of."     On  examination,  nothing  was   to  be  detected  by  rectal 

1  Surgery  of  the  Rectum,  London,  1871.  2  Op.  cit.,  p.  565. 


33 G  DISEASES    OF    THE    HECTUM    AND    ANUS. 

touch,  but  the  pelvis  at  its  upper  part  was  partially  filled  by 
firm,  nodular  masses,  which  extended  deeply  down  into  the 
right  iliac  fossa.  The  patient  had  no  conception  of  any  trouble 
beyond  constipation  and  "rheumatism,"  though  the  whole 
lower  extremity  on  the  right  side  was  oedematous.  By  careful 
diet  and  laxatives  the  threatened  obstruction  was  avoided,  and 
the  man  gradually  sank  with  all  the  signs  of  the  cancerous 
cachexia,  and  died  three  months  from  the  first  examination. 
Unfortunately  no  autopsy  could  be  obtained. 

From  what  has  been  said,  it  is  evident  that  there  is  little  in 
the  history  which  the  patient  will  give  of  cancer  of  the  rectum 
to  distinguish  it  from  ulceration  and  stricture  of  any  other  vari- 
ety, and  that  the  diagnosis  must  chiefly  rest  upon  a  physical 
examination.  To  make  such  an  examination  thoroughly,  and 
yet  safely,  requires  great  care  and  gentleness,  and  to  properly 
interpret  the  conditions  which  may  be  found,  no  little  experi- 
ence and  knowledge.  It  requires  many  years  of  practice  to 
reach  the  point  Allingham  has  reached  when  he  says:  "There 
is  something  peculiar  about  the  feel  of  cancer  which  the  prac- 
tised finger  rarely  mistakes  even  for  simple  indurated  ulceration. 
I  think  it  is  many  years  now  since  I  mistook  the  one  for  the 
other." 

In  the  majority  of  cases  the  diagnosis  may  be  made  by  the 
history  and  by  physical  examination  with  the  finger  alone. 
Cancer  in  this  locality  is  a  disease  of  rapid  growth,  and  when  a 
patient  says  that  stricture  has  existed  any  considerable  number 
of  years  the  idea  of  malignancy  may  be  abandoned.  Something 
also  may  be  learned  from  the  general  appearance  of  the  patient, 
but  most  of  all  from  the  digital  examination.  When  the  dis- 
ease is  seen  in  its  earlier  stages,  the  hard,  more  or  less  distinctly 
circumscribed  new  growth  which  has  infiltrated  the  wall  of  the 
bowel  is  diagnostic.  (Fig.  84.)  The  great  difficulty  is  to  distin- 
guish between  an  advanced  case  where  the  rectum  is  partially 
occluded  by  hard  masses  of  disease,  and  an  old  case  of  stricture 
and  ulceration  which  is  not  malignant.  This  may  sometimes 
be  impossible  except  by  the  microscope,  and  syphilitic  disease 
of  the  rectum  is  not  infrequently  mistaken  for  cancer.  When  a 
<oft,  friable  mass  of  epithelioma  is  found  seated  on  a  hard,  infil- 
trated  base  which  is  ulcerated  in  spots,  the  edges  of  the  ulcers 
being  hard  and  raised,  the  diagnosis  is  also  easy. 

Cancerous  stricture  of  the  sigmoid  flexure  will   show  itself 


CANCER. 


337 


x     w; 


sooner  or  later  either  by  examination  through  the  abdominal 
wall,  or  by  the  signs  of  intestinal  obstruction. 
4  In  cases  where  the  condition  is  more  complicated  and  where 
secondary  deposits — in  the  liver,  for  example — have  begun  to 
do  their  fatal  work  before  actual  obstruction  has  begun,  these 
symptoms  of  stricture  may  all  be  obscured  by  the  presence  of 
others  which  shall  more  readily  attract  the  eye.  In  a  case  which 
I  now  have  under  treatment,  I  had  made  the  diagnosis  of  cancer 
of  the  liver  with  ascites  and  great  intestinal  disturbance  some 
time  before  my  attention  was  called  to  the  rectum,  and  it  be- 
came evident  by  examination  that  the  affection  of  the  liver  was 


Fig.  84. — Cancer  of  the  Rectum.    (Agnew.) 

secondary  to  malignant  disease  high  up  in  the  rectum,  which 
was  also  gradually  involving  the  pelvic  viscera.  The  greatest 
caution  should  be  exercised  in  the  examination  for  cancerous 
disease  above  the  lower  four  inches  of  the  rectum.    Ls* 

Treatment. — The  treatment  of  malignant  disease  of  the  rec- 
tum is  designed  to  be  either  curative  or  palliative.  In  a  small 
number  of  selected  cases  a  cure  is,  perhaps,  possible,  as  with 
cancer  of  feeble  malignancy  in  other  parts  of  the  body — e.g., 
epithelioma  of  the  lip.  At  all  events,  the  disease  may  be  re- 
moved, and  its  return  delayed  for  many  years.     This  fact,  we 

22 


338  DISEASES    OF   THE    RECTUM    AND    ANUS. 

believe,  may  be  accepted  as  proved  by  a  sufficient  number  of 
carefully  examined  cases,  from  which  the  chances  of  error  in 
diagnosis  and  subsequent  history  have  been  eliminated.  Cure 
can,  however,  only  be  effected  by  excision.  All  other  means 
may  be  set  aside  as  hopeless  failures. 

The  operation  of  excision,  which,  after  being  fully  described 
and  ably  advocated  by  Lisfranc  in  1830,  was  allowed  to  fall  into 
disuse,  has  again,  within  the  past  few  years,  become  popular. 
It  would  probably  be  a  waste  of  time  to  inquire  to  whom  the 
credit  of  reviving  it  is  due.  Cases  of  its  occasional  performance 
are  scattered  through  the  surgical  literature  of  the  rectum  from 
the  early  part  of  the  century  to  the  present,  and  just  now  it  is 
at  the  height  of  its  popularity.  Like  every  other  surgical  pro- 
cedure at  that  point  of  its  history,  it  is  perhaps  also  occasion- 
ally done  when  it  were  better  to  be  content  with  less  radical 
measures.  As  a  result  of  a  careful  search  among  the  statistics 
of  this  operation,  Cripps '  gives  the  following  figures.  Out  of 
a  total  of  sixty -four  cases,  eleven  died  as  a  direct  result  of  the 
operation,  six  from  peritonitis,  one  from  cellulitis,  and  four 
from  accidents  incident  upon  any  surgical  interference. 

In  the  fif't}^-three  cases  of  recovery,  the  subsequent  history 
is  unknown  in  sixteen,  and  in  three  more  the  diagnosis  was  so 
doubtful  as  to  exclude  them  from  the  list.  No  case  is  worth 
much  in  the  consideration  of  a  question  such  as  this  where  the 
diagnosis  has  not  been  verified  by  the  microscope  in  competent 
hands,  for  there  are  non-malignant  growths  of  this  part  which, 
to  the  naked  eye,  strongly  resemble  cancer.  We  have  then  a 
remainder  of  thirty-four,  in  whom  the  disease  returned  in 
twenty  ;  but  of  these  twenty,  several  were  operated  on  a  second 
time  for  a  recurrence  of  the  growth,  or  possibly  for  a  small 
nodule  which  had  not  been  removed  at  the  first  operation,  and 
after  this  second  operation  remained  free.  This  leaves,  how- 
ever, a  total  of  twenty-three  out  of  sixty-four  operations  in 
which  tli"  disease  had  not  returned  after  an  interval  varying 
from  a  few  months  to  over  four  years — a  limit  reached  in  three 

<;i<es. 

Tli  is  is  certainly  an  encouraging  result  for  this  disease,  and 
the  fact  that  undoubted  cancer  may  be  removed  and  not  reap- 
pear for  such  a  length  <>f   time  is  decisive.     Some   operators, 

'Op.  cit.,  p.  1GG. 


CANCER.  •      339 

however,  report  better  results  than  these,  and  some  have  not 
been  so  successful.  Curling1  gives  one  case  of  removal  of  an 
epithelioma  in  which  there  had  been  no  return  in  the  rectum 
after  seven  years,  though  for  one  year  there  had  been  "  a  doubt- 
ful tumor  of  the  pelvis."  Velpeau  and  Verneuil  each  report 
cases  in  which  the  cure  has  seemed  permanent,  and  Chassaignac 
gives  several  in  which  there  had  been  no  return  after  six  years. 
Dieffenbach's  thirty  cases  in  which  the  patients  lived  many 
years  without  a  return  are  generally  looked  upon  with  sus- 
picion. Allingham,2  on  the  contrary,  considers  the  partial  re- 
moval of  the  circumference  of  the  bowel  as  unsatisfactory.  In 
all  of  his  thirteen  cases  in  which  he  was  able  to  follow  the  prog- 
ress of  the  case  for  one  year,  there  was  either  a  return  of  the 
growth  in  the  rectum  or  the  glands  in  the  groin  became  affected, 
and  there  ensued  disease  in  the  internal  organs.  In  four  cases 
the  disease  did  not  return  in  the  bowel,  but  in  the  inguinal 
glands,  proving  that  it  was  not  due  to  an  incomplete  operation. 
With  regard  also  to  his  ten  cases  of  total  extirpation,  he  speaks 
very  cautiously.  He  believes  that  a  cure  is  very  uncommon, 
and  not  generally  to  be  expected,  and  he  does  not  commit  him- 
self even  on  the  question  of  the  prolongation  of  life.  The  mor- 
tality, as  a  direct  result  of  the  operation,  is  generally  about 
twenty-five  per  cent.3 

Billroth4  reports  thirty-three  cases.  Thirteen  died  of  the 
operation,  and  the  remainder  all  died  within  two  years,  most  of 
them  of  recurrence. 

The  deaths  immediately  following  the  operation  were  in- 
variably due  to  retro-peritoneal  suppuration,  characterized  by 
acute  septic  symptoms.  Most  of  them  died  within  from  four 
to  eight  days. 

Since  then,  in  certain  cases,  we  are  justified  in  expecting  re- 
covery from  the  operation  itself,  and  such  a  length  of  life  as 
would  not  result  were  the  disease  left  to  its  natural  course,  we 
may  ask:  1.  What  are  the  dangers,  and  what  is  the  mortality 
of  the  operation  ?  2.  In  what  class  of  cases  is  it  applicable  ? 
3.  What  are  its  results  as  a  curative  and  as  a  palliative  mea- 
sure, and  how  do  these  results  compare  with  those  of  lumbar 

1  Diseases  of  the  Rectum,  ed.  of  1870,  p.  164.  2  Loc.  cit.,  p.  277. 

3Molliere:   Traite  des  Maladies  du  Rectum  et  de  l'Anus,  Paris,  1877,  p.  627. 
4  Clinical  Surgery.     Extracts  from  the  Reports  of  Surgical  Practice  between  the 
Years  1860-1876.     By  Th.  Billroth,  New  Sydenham  Society,  1881. 


340  DISEASES    OF    THE    KECTUM   AND    ANUS. 

colotomy  ?  4.  What  are  the  results  as  regards  the  subsequent 
condition  of  the  bowel,  and  the  control  of  the  faecal  evacuations  ? 
5.   What  is  the  best  method  of  its  performance  % 

For  the  purpose  of  arriving  at  a  knowledge  of  what  expe- 
rience has  already  taught  in  this  matter,  I  collected,  several 
years  ago,1  the  reports  of   operations  up  to   that   time  as  far 

1  For  the  full  literature  of  the  cases  upon  which  these  conclusions  are  based,  the 
reader  is  referred  to  the  following  bibliography  : 
Ag.new.- Phila.  Med.  Times,  June  23,  1877. 
Allingham. — Diseases  of  the  Rectum,  3d  ed. ,  London,  1879. 
Briddon.—  Med.  Record,  January  6, 1877. 

Bushe. — Treatise  on  Diseases  of  the  Rectum,  New  York,  1837,  p.  294. 
Byrne. — Annals  of  the  Anat.  and  Surg.  Soc,  May,  1880. 
Batjmes.— Bull,  de  l'Acad.  Roy.  de  Med.,  t.  x.,  p.  936. 
Chassaignac. — Traite  de  l'ecrasement  lineaire,  Paris,  1856. 
Cripps. — Cancer  of  the  Rectum. 
Crosse  (quoted  by  Mayo). — Observations  on  Diseases  and  Injuries  of  the  Rectum, 

London,  1833,  p.  210. 
Curling. — Observations  on  Diseases  of  the  Rectum,  London,  1851.     Med.   Times 

and  Gaz.,  March  14,  1857. 
Dennonvilliers. — Gaz.  des.  Hop.,  1844. 

Desgranges  (quoted  by  Molliere). — Maladies  du  Rectum,  etc.,  Paris,  1877,  p.  627. 
Dieffenbach. — Die  operative  Chirurgie,  Leipzig,  1845. 
Dolbeau. — These  de  Fumouze. 
Duplav.— Gaz.  Med.  de  Paris,  1872,  p.  486. 

Dupuy.— Bull,  de  la  Soc.  Anat.,  Paris,  1872.     2me  s.,  xvii.,  p.  242. 
Emmet. — Principles  and  Practice  of  Gynecology,  1st  ed. ,  Philadelphia,  1879,  p. 

511. 
Ewart. — Lancet,  June  21,  1879. 
Fenwick. — Montreal  Gen.  Hosp.  Reports,  vol.  i. 
Gay.— Lancet,  June  28,  1879. 
Gosselin.— Gaz.  des.  Hop.,  1879,  p.  921. 
Holmer.—  Hospitals-Tidende,  March  31,  April  7,  14.  1880. 
Holmes. — Trans,  of  the  Clin.  Soc.  of  London,  1878,  p.  113. 
Holt  (quoted  by  Curling),  op.  cit. 
Keyes.— Arch,  of  Med.,  August,  1879. 
King.— Brit  Med.  Jour.,  June  21,  1879. 
Kumab.— Wiener  Med.  Woch.,  1878.  p.  1070. 
Labbe.— Gaz.  des  Hop.,  June  4,  18,  1880. 
Levis.— Arch,  of  Clin.  Surg.,  February,  1877. 
LlBFBANC. — These  de  Pinault,  182".). 

Majsonneuve. — Union  M;d.,  1805.     Also  These  de  Cortes,  1860. 
Mandt.—  Revue  M<'d.,  1886,  p.  204. 
March.— Trans,  of  tin:  N.  V.  State  Med.  Soc,  1868  ;  also  Med.  and  Surg.  Reporter, 

June  9,  1877. 
Mayo. — Observations  on  Diseases  and  Injuries  of  the  Rectum,  London,  1883,  p. 

212 
Moore.— Med.  Times  and  Gaz.,  March,  1857. 


CANCER.  341 

as  tliey  were  then  attainable.  The  list  at  that  time  included 
one  hundred  and  forty  cases,  and  I  arrived  at  the  following 
general  conclusions  concerning  the  operation,  which  subsequent 
study  of  the  question  has  led  me  in  no  way  to  alter. 

1.  AWiough  there  ham  been  a  few  cases  of  excision  in 
loliicJi  the  cancer  has  not  returned  in  a  number  of  years,  such 
a  result  is  so  rare  as  not  to  justify  the  exposure  of  the  patient 
to  the  risk  of  immediate  death  which  attends  the  attempt  to  re- 
move extensive  disease. 

Regarding  the  question  of  radical  cure,  we  find  difficulty  in 
establishing  exact  dates,  and  have  to  take  into  consideration 
the  reputation  of  the  reporter.  We  find,  however,  that  in  one 
hundred  cases  (deducting  those  immediately  fatal,  and  seven- 
teen which  passed  out  of  observation  immediately  after  opera- 
tion) we  have  five  cases  of  reported  permanent  cure,  in  which 
there  had  been  no  return  for  at  least  ten  years.  Three  of  these 
are  reported  by  Volkmann,  and  two  by  Velpeau.  March,  of 
Albany,  has  been  credited  with  another  case  of  radical  cure,  but 
the  author  is  much  indebted  to  the  present  Dr.  March  for  a 
letter  stating  that  the  case  of  supposed  radical  cure  reported  by 
his  father  passed  out  of  observation  at  the  end  of  one  year. 
There  are  some  other  cases  which  have  been  included  in  the 


MoLLlfeRE. — These  de  Carcopino,  1879. 

Nussbatjm. — Aerztlich.  Intelligenzblatt,  1863. 

O'Hara. — Phila.  Med.  Times,  vol.  viii. 

Paget  (quoted  by  Cripps),  op.  cit. 

Peters. — Arch,  of  Med.,  August,  1879. 

Pital  du  Cateau.— L'Experience,  t.  vi. ,  p.  27. 

Polaillon. — Gaz.  des  Hop.,  1879. 

Post.— Med.  Record,  July  31,  1880. 

Recamier. — These  de  Masse,  1842. 

Roddick. — Montreal  Gen.  Hosp.  Reports',  vol.  i. 

ScnuH. — Abhandlung  der  Chir.  und  Operationslehre,  Wien,  1867. 

Siebold  (quoted  by  Curling),  op.  cit. 

Simon.— Lancet,  1851,  ii.,  1882. 

Simon,  of  Rostock.— Deutsche  Klinik,  1866. 

Stimson.— Arch,  of  Med.,  August,  1879. 

Terrillon.— These  de  Carcopino,  1879. 

Van  Buren.— Arch,  of  Med.,  August,  1879. 

Van  Derveer.— Med.  Record,  September  20,  1879. 

Velpeau.— Nouveaux  Elemens  de  Med.  Operatoire,  Paris,  1839,  vol.  iv.,  p.  814. 

Verneuil  (quoted  by  Marchand).— Etude  sur  l'Extirpation  de  l'Extremite  In- 

ferieure  du  Rectum. 
Volkmann.— Klin.  Vortriige,  March  13,  1880. 


342  DISEASES    OF    THE    RECTUM    AND    ANUS. 

category  of  permanent  cures — cases  in  which  the  disease  had 
not  returned  in  four  or  five  years — but  the  great  majority  recur 
within  the  first  year  and  are  fatal  within  two. 

2.  The  operation  is  chiefly  valuable  as  a  palliative  measure, 
and  as  such  it  compares  favorably  with  colotomy  both  in  pro- 
longing life  and  relieving  pain. 

The  treatment  of  cancer  of  the  rectum  by  excision  has  not 
yet  been  accepted  by  the  surgical  world  as  a  substitute  for  other 
measures,  even  in  cases  best  adapted  for  the  operation,  although 
it  cannot  be  denied  that  a  radical  cure  has  sometimes  been  ob- 
tained, and  that  in  many  other  cases  life  has  been  prolonged 
beyond  what  could  have  been  hoped  for  by  any  other  means  of 
treatment.  It  is  no  less  true  that  the  operation  is  one  of  great 
danger,  and  that  there  are  not  lacking  those  whose  experience 
has  led  them  to  believe  that  life  was  rather  shortened  than 
lengthened  by  it.  By  these  it  is  claimed  that  in  lumbar  colot- 
omy we  have  a  safer  method  of  relieving  pain  and  delaying  the 
progress  of  the  growth,  and  in  both  these  ways  prolonging  life. 
American  and  British  surgeons  hold  rather  to  this  latter  idea, 
while  the  French  and  the  Germans  favor  excision. 

Excision  can  scarcely  be  judged  in  comparison  with  colot- 
omy, being  applicable  properly  only  to  an  entirely  different 
class  of  cases.  In  cancer  above  four  inches  from  the  anus, 
colotomy  or  colectotomy  are  about  the  only  means  of  relief.  In 
cancer  within  four  inches  of  the  anus  almost  any  other  plan  of 
treatment  is  preferable. 

This  leads  me  to  call  attention  to  another  point — the  opera- 
tion of  excision  as  a  palliative  measure.  In  cases  properly 
chosen,  where  the  disease  is  not  so  extensive  as  to  render  its 
removal  one  of  the  capital  surgical  operations,  we  know  of 
nothing  better,  and  this  fact  cannot  fail  to  be  deeply  impressed 
upon  the  reader  of  these  cases.  The  statement  that  all  suffer- 
ing was  relieved  is  almost  invariable.  In  almost  every  case  at- 
tention is  called  to  the  great  improvement  in  general  health,  the 
loss  of  pain,  and  the  increase  in  strength.  Patients  go  away 
believing  themselves  radically  cured,  return  to  their  employ- 
ments, and  are  reported  by  the  French  surgeons  as  "parfaite- 
ment  gueries,"  a  few  weeks  after  the  operation. 

It  has  been  claimed '  against  this  operation  that  even  when 
a  good  immediate  result  is  obtained,  it  may  shorten  life  by 

1  Labbe:  Gaz.  Hebdom.,  June  4,  18,  1880. 


CANCER.  343 

hastening  the  return  and  final  progress  of  the  disease.  Unfor- 
tunately, it  is  difficult  to  tell  in  any  particular  case  how  long  a 
patient  would  have  lived  had  the  disease  been  left  to  its  course  ; 
but,  accepting  as  a  basis  for  comparison  Allingham's  estimate 
of  the  average  duration  of  life  in  cancer  of  the  rectum  as  two 
years  or  less,  we  are  justified  in  concluding  that  in  all  cases 
where  life  was  prolonged  more  than  one  year  and  a  half  after 
the  time  of  operation  (the  operation  generally  being  done  late 
in  the  disease),  this  length  of  life  may  fairly  be  attributed  to 
the  surgical  interference.  This  estimate  is  manifestly  a  small 
one,  for  a  study  of  the  cases  makes  it  evident  that  many  who  did 
not  live  eighteen  months  after  the  operation  yet  gained  a  con- 
siderable length  of  comfortable  existence  ;  and  there  is  nothing 
to  prove  that  in  any  case  the  operation  hastened  the  natural 
course  of  the  disease. 

I  have  carefully  searched  the  record  of  cases  in  which  a  re- 
turn of  the  disease  within  six  months  of  the  time  of  operation  is 
reported,  to  discover  whether  here  also  there  was  any  marked 
relation  between  this  result  and  the  nature  or  extent  of  the 
disease  at  the  time  of  operation  ;  but  it  is  especially  at  this 
point  that  the  table  fails  us.  A  proper  answer  to  this  question 
involves  not  only  a  careful  report  of  the  extent  of  the  disease, 
but  a  microscopic  study  of  its  character,  and  such  data  are 
given  only  in  a  relatively  small  proportion  of  cases.  I  believe, 
however,  that  the  cases  show  a  marked  relation  between  the 
rapidity  of  the  growth  before  operation  and  the  speedy  return 
after  removal. 

We  can  trace  no  connection  between  the  time  of  the  return 
and  the  extent  of  the  disease  removed  when  the  removal  has 
been  complete  ;  and  the  microscopic  reports  are  too  few  for  gen- 
eral conclusions  to  be  drawn  from  them.  I  know  of  no  writers, 
except  Stimson  and  Holmer,  who  have  made  a  careful  study  of 
the  specimens  excised  and  have  given  the  results  ;  and,  so  far 
as  the  clinical  reports  of  the  German  operators  go,  they  would 
seem  to  give  support  to  their  practice  of  removing  everything 
involved,  no  matter  how  extensive,  in  the  hope  that  the  local 
return  may  be  long  delayed. 

3.  When  the  disease  readies  above  three  inches  from  the 
anus,  or  involves  neighboring  parts  so  as  to  render  its  entire 
removal  without  injury  to  the  peritoneum  questionable,  the 
operation  is  contra-indicated. 


3-14  DISEASES    OF    THE    RECTUM    AND    ANUS. 

The  Germans  have  apparently  no  limits  to  the  applicabil- 
ity of  this  operation.  They  perform  it  in  cases  of  the  most  ex- 
tensive disease,  opening  the  peritoneum,  exsecting  the  sacrum 
when  necessary  to  reach  its  upper  limit,  and  removing  the  pros- 
tate and  base  of  the  bladder  when  they  are  implicated,  balanc- 
ing the  risk  of  immediate  death  from  the  operation  against  the 
chance  of  radical  cure,  or  prolonged  immunity  from  return. 
Conservative  surgeons  will  hesitate  long  before  accepting  this 
view,  for,  although  very  satisfactory  results  have  been  obtained 
in  such  cases,  they  can  hardly  be  considered  other  than  excep- 
tional, and  a  study  of  cases  shows  that  the  frequency  of  the 
fatal  result  is  in  direct  proportion  to  the  extent  of  the  operation 
attempted.  The  rules  for  the  selection  of  cases  laid  down  by 
Lisfranc  were  these  :  -when  the  bowel  is  movable,  in  other  words, 
when  the  disease  has  not  involved  surrounding  parts,  the  oper- 
ation should  be  undertaken.  When,  on  the  other  hand,  the 
disease  is  more  extensive  and  reaches  higher,  he  leaves  the 
question  to  be  decided  by  future  experience.  I  believe  that 
experience  has  now  decided  against  it.  In  deciding  for  or 
against  the  operation,  an  examination  of  the  glands  in  the  hol- 
low of  the  sacrum  and  in  the  loins  is  of  great  value,  for  these 
receive  their  lymph  directly  from  the  rectum,  and  may  be  en- 
larged, while  those  in  the  groin,  which  are  supplied  from  the 
skin  around  the  anus,  may  still  be  uninvolved. 

I  shall  not  stop  at  this  time  to  again  discuss  the  question  as 
to  how  much  of  the  anterior  wall  of  the  rectum  is  uncovered  by 
peritoneum,  but  must  refer  the  reader  to  the  chapter  on  anat- 
omy. The  height  to  which  it  is  safe  to  go  cannot  be  definitely 
stated  for  all  cases,  the  reflection  of  the  serous  coat  upon  the 
rectum  being  at  a  variable  point.  Fochier  '  reports  a  case  in 
which  he  used  the  ecraseur  at  twelve  centimetres  without  harm, 
and  Allingham,2  who  is  always  a  safe  guide,  has  seen  all  but 
the  lower  two  inches  of  the  bowel  covered  by  peritoneum  in  a 
female,  has  opened  into  it  in  a  male  when  not  more  than  three 
and  one-half  inches  were  removed,  and  has  taken  away  fully 
five  inches  in  a  male  without  bringing  it  into  view. 

There  is  an  old  rule  for  applying  the  trephine,  that  in  every 
instance  the  operator  should  remember  that  some  skulls  are 
very  much  thinner  than  others,  and  he  should  act  on  the  sup- 

1  Lyon  Med.,  February  20,  1870.  s  Op.  cit.,  p.  275. 


CANCER.  345 

position  that  the  particular  point  upon  which  he  is  operating  is 
the  thinnest  part  of  the  thinnest  skull  ever  seen.  Something  of 
the  same  kind  might  be  said  of  the  peritoneum  over  the  rectum  ; 
and  everybody  who  has  studied  the  anatomy  of  the  part  knows 
how  various  are  the  opinions  of  different  authorities  on  this 
point.  Nevertheless,  a  line  of  danger  can  be  marked  out,  and 
that  line  is  about  three  inches  from  the  anus.  It  is  true  that 
more  than  this  amount  of  the  rectum  has  been  removed  without 
encountering  the  peritoneum,  and  it  has  been  opened  below  this 
point  ;  but  I  should  not,  for  my  own  part,  hesitate  to  try  to 
remove  three  inches  of  the  bowel  for  a  cancer,  and  I  have  refused 
to  attempt  to  extirpate  in  an  otherwise  suitable  case  because  the 
disease  passed  this  line.  The  index  finger  is  a  good  guide.  What 
is  well  within  its  reach  in  a  hand  of  good  length  it  is  safe  to 
try  to  remove,  provided  it  does  not  involve  surrounding  tissues 
to  an  extent  which  renders  its  complete  removal  impossible. 
Whatever  may  be  said  of  the  impunity  with  which  the  periton- 
eum may  be  opened  in  other  parts  of  the  body  does  not  seem  to 
apply  here  ;  for  I  have  been  able  to  find  but  three  cases  in 
which  that  accident  was  not  followed  by  a  fatal  result. 

Unfortunately,  the  disease  is  but  rarely  seen  at  a  stage  when 
extirpation  is  justifiable  ;  that  is,  when  it  is  limited  to  a  circum- 
scribed spot  within  three  or  three  and  a  half  inches  of  the  anus, 
when  it  is  movable  on  the  muscular  coat,  has  not  invaded  the 
deeper  tissues,  and  before  there  has  been  any  glandular  en- 
largement. 

Although  there  is  a  very  evident  relation,  which  is  shown  by 
a  study  of  the  statistics  of  the  operation,  between  the  extent  of 
the  operation  attempted  and  the  favorable  or  unfavorable  results 
obtained,  a  fatal  result  will  often  follow  the  extirpation  of 
disease  which  is  comparatively  slight  in  amount.  The  three 
great  dangers  of  the  operation  are  peritonitis,  pelvic  cellulitis, 
and  septicaemia.  Haemorrhage  may  fairly  be  dropped  out  of 
consideration,  for  the  operation  may,  if  desired,  be  rendered 
almost  bloodless  by  the  use  of  the  ecraseur  or  galvano-cautery. 

4.  The  operation  is  not  followed  by  any  annoying  after- 
consequences  which  are  of  sufficient  gravity  to  contra-indicate 
its  performance. 

In  a  small  proportion  of  cases  there  will  be  complete  incon- 
tinence, in  a  greater  number  there  will  be  partial  control  over 
the  evacuations,  and  in  a  majority  the  control  will  be  sufii- 


346  DISEASES    OP   THE    RECTUM    AND    ANUS. 

ciently  complete  to  prevent  the  occurrence  of  any  annoying 
accident. 

Stricture  to  a  troublesome  extent  is  also  rare,  and  when  it 
exists  it  may  generally  be  overcome  by  the  introduction  of 
bougies.  In  one  case  reported  by  Verneuil,  a  special  plastic 
operation  was  performed  to  relieve  this  condition,  an  account 
of  which  may  be  found  in  the  work  of  Marchand.1 

Regarding  the  best  way  of  performing  the  operation,  the 
surgeon  has  his  choice  of  several.  The  first  case  of  extirpation 
of  the  rectum  of  which  we  have  any  record  was  by  Faget,  in 
1739,  and  was  not  for  cancer,  but  simply  a  removal  of  the  lower 
portion  of  the  bowel,  which  had  been  completely  surrounded 
and  denuded  by  an  abscess  beginning  in  one  ischio-rectal  fossa, 
and  subsequently  extending  into  the  other.  From  that  time 
until  1826  the  operation,  as  a  means  of  treatment  of  cancer, 
will  occasionally  be  found  mentioned  in  surgical  literature ; 
generally,  however,  only  in  condemnation.  In  1826  Lisfranc 
performed  the  first  successful  operation  for  cancer  ;  and  three 
years  later  his  student,  Pinault,  in  a  these  reported  nine  cases, 
and  gave  to  the  procedure  a  permanent  place  in  literature  and 
practice.  In  1833  Lisfranc  himself  embodied  the  same  ideas  in 
a  paper  read  before  the  Acad.  Royale  de  Medecine,2  and  from 
that  time  the  operation  became  widely  known.  Since  then  it 
has  had  its  advocates  and  opponents,  and  has  been  subject  to 
many  modifications  in  its  performance.  For  a  long  time  it  was 
coolly  received  by  British  surgeons,  but  within  the  past  decade 
it  has  received  a  new  stimulus  from  the  Germans,  and  at  the 
time  of  writing  it  seems  to  have  been  fairly  tried  by  the  surgical 
world,  and  can  now  be  judged  on  its  merits. 

Almost  every  surgeon  whose  name  is  prominently  associated 
with  the  operation  has  had  his  own  favorite  way  of  performing 
it ;  and  we  shall,  therefore,  speak  in  detail  only  of  those  which 
have  proved  most  acceptable,  and  first  of  those  described  by 
Volkmann  in  his  Klinisclie  Vortrage  for  March  13,  1880.  He 
describes  three  different  operations,  depending  on  the  location 
of  the  disease.  The  first  is  for  the  removal  of  a  circumscribed 
spot  only.  This  is  accomplished  by  dilating  the  anus,  dragging 
down  the  disease,  and  excising  it  in  such  a  way  that  the  wound 

1  Etude  sur  1' extirpation  de  rextremito  inferieure  du  rectum.     Marchand,  Paris, 
1873. 

1  Mem.  de  l'Acad.  Roy.  de  Med.,  1833,  iii.,  p.  296. 


CANCER.  347 

shall  not  cause  subsequent  stricture.  When  the  growth  in- 
volves the  anus,  the  edges  of  the  wound  are  carefully  brought 
together,  stitched  with  catgut,  and  a  drainage-tube  inserted 
between  them.  When  the  growth  is  entirely  within  the  sphinc- 
ter, the  edges  are  brought  together  with  equal  care,  but  the 
tube  is  inserted  through  a  track  made  for  it,  which  communi- 
cates with  the  wound  above,  and  perforates  the  healthy  skin  at 
a  point  outside  of  the  border  of  the  sphincter.  When  dilata- 
tion does  not  suffice,  the  anus  is  freely  divided  down  to  the  coc- 
cyx, and  this  wound  is  subsequently  carefully  closed  under  the 
antiseptic  precautions. 

In  the  second  class  of  cases  where  the  growth  involves  the 
whole  circumference  of  the  bowel,  but  not  the  anus,  the  latter  is 
divided  forward  into  the  perinseum,  and  backward  to  the  tip  of 
the  coccyx,  when  necessary,  to  give  room  for  manipulation. 
The  latter  of  these  two  incisions  is  carried  as  far  into  the  bowel 
as  the  lower  border  of  the  disease,  which,  is  then  removed.  The 
mucous  membrane  above  is  stitched  to  that  below,  the  prelim- 
inary incisions  carefully  closed,  and  a  drainage-tube  left  in  the 
posterior  one. 

In  the  third  class,  where  the  disease  involves  all,  or  nearly 
all,  of  the  anus  and  of  the  circumference  of  the  rectum,  the 
entire  tube  is  separated  and  removed  in  a  cylinder.  The  same 
preliminary  incisions  may  be  made  as  in  the  second  class,  and 
the  anus  is  surrounded  by  a  circular  cut,  which  runs  outside 
the  sphincter.  From  this  as  a  starting-point,  the  dissection  is 
carried  parallel  with  the  bowel  till  the  upper  portion  of  the  dis- 
ease is  passed.  By  the  use  of  knife,  scissors,  and  fingers  the 
bowel  is  completely  freed,  then  drawn  down  to  the  anus,  and 
cut  off  above  the  disease,  the  healthy  upper  end  being  stitched 
to  the  margin  of  the  skin.  In  case  the  peritoneum  is  opened, 
the  wound  is  at  once  stuffed  with  carbolized  sponge,  and  after- 
ward carefully  closed  with  catgut.  The  coccyx  and  part  or 
nearly  all  of  the  sacrum  are  removed  when  necessary  to  make 
room,  as  a  preliminary  step. 

The  risk  of  haemorrhage  is  one  of  the  great  objections  to  this 
operation,  and  later  on  we  shall  describe  another  procedure, 
which  is  preferred  by  many,  in  which  the  knife  is  supplanted 
by  other  and  bloodless  instruments.  It  is  no  doubt  true  that 
the  deep  dorsal  incision  is  the  key  to  the  operation,  and  greatly 
facilitates  the  securing  of  bleeding  vessels,  yet  the  heemorrhage 


348  DISEASES    OF    THE    RECTUM    AND    ANUS. 

ma}7  be  so  great  as  to  impede  the  operator  and  endanger  the 
life  of  the  patient.  It  will  be  seen  that,  at  every  step  in  this 
operation,  union  by  first  intention  is  aimed  at.  and  Listers 
methods  are  carefully  followed.  If  the  elements  of  success  in 
Listerism  are,  as  I  believe,  cleanliness  and  drainage,  these  are 
certainly  better  met  by  a  deep  posterior  wound,  which  is  left 
open  and  syringed  out  frequently,  than  by  carefully  closing 
that  safety-valve  with  cat-gut  sutures  and  inserting  a  drainage- 
tube.  It  will  also  be  observed  that  the  bowel  is  always  brought 
down  and  stitched  to  the  free  edge  below.  To  do  this  much 
dissecting  is  necessary,  and  but  little  permanent  good  is  gained, 
as  the  stitches  soon  tear  out. 

Maisonneuve  described,  in  L^Urtion  mkllcale  of  1860,  an 
operation  which  he  named  the  procede  de  la  ligature  exteinpo- 
ranee,  and  which  differs  from  the  preceding  in  being  almost 
entirely  bloodless,  although  it  differs  little  from  the  operation 
previously  described  by  Chassaignac,  under  the  name  Vecrase- 
ment  lineaire.  In  the  latter,  the  rectum  is  divided  into  two 
lateral  halves  by  the  chain  ecraseur,  and  each  half  of  the  dis- 
ease is  then  attacked  in  the  same  way  and  removed.  In  the 
operation  as  done  by  Maisonneuve,  a  strong  cord  is  substituted 
for  the  chain,  and  the  disease  is  removed  in  the  following 
manner.  The  skin  and  subcutaneous  tissue  are  divided  by  a 
circular  incision  which  completely  surrounds  the  anus.  The 
operator  is  provided  with  several  strong  curved  needles,  each  of 
which  is  to  be  threaded  through  the  point  as  often  as  used,  with 
a  strong  silk  ligature  about  a  foot  in  length.  One  of  the 
needles  with  the  ligature  in  its  point  is  then  passed  from  the  ex- 
ternal incision  into  the  bowel  above  the  growth,  going  wide  of 
the  gut  to  clear  the  tumor.  The  loop  of  string  in  the  eye  of  the 
needle  is  seized  within  the  rectum  and  drawn  out  of  the  anus, 
while  the  needle  is  drawn  back  out  of  its  own  track.  The  result 
of  this  is  a  double  uncut  ligature,  passing  from  the  point  where 
the  needle  entered  the  external  incision,  outside  of  the  tumor, 
into  the  rectum  above  it,  and  then  out  of  the  anus,  and  this 
manoeuvre  is  repeated  eight  or  nine  times  at  points  around  the 
circumference  of  the  anus  equidistant  from  each  other.  A 
strong  whip-cord  or  bow-string  is  the  next  requisite — about  two 
yards  long — and  to  this  all  the  loops  hanging  from  the  anus  are 
attached  at  points  nine  inches  distant  from  each  other.  Each 
of  the  original  ligatures  is  then  withdrawn  by  the  same  course 


CANCER.  349 

it ■  entered,  carrying  a  loop  of  the  whip-cord  with  it.  When  all 
are  drawn  out,  the  rectum  above  the  disease  is  surrounded  by 
a  series  of  loops  of  strong  cord,  and  the  ends  of  each  loop  hang 
oat  from  the  original  incision.  The  ends  are  then  attached  to 
an  ecraseur,  and  each  loop  made  to  cut  its  way  out  in  turn. 
After  all  have  been  cut  out,  the  lower  end  of  the  bowel  and  the 
diseased  mass  are  of  necessity  completely  separated  from  their 
attachments. 

The  operation  performed  by  Cripps  is  a  modification  of  the 
two  preceding  ones,  and  would  seem  to  possess  several  advan- 
tages in  facility  of  performance.  The  preliminary  dorsal  incision 
is  made  from  within  outward,  by  passing  a  strong  curved  bis- 
toury into  the  rectum,  bringing  its  point  through  the  skin  at 
the  tip  of  the  coccyx,  and  cutting  all  the  intervening  tissue. 
The  buttock  is  then  drawn  away  from  the  anus  to  put  the  tis- 
sues on  the  stretch,  and  a  lateral  incision  made  from  the  pre- 
liminary cut  behind,  around  the  rectum  to  the  median  line  in 
front.  The  site  of  this  incision,  whether  inside  or  outside  the 
anus,  will  depend  upon  the  location  of  the  disease,  and  whether 
or  not  the  anus  is  implicated.  The  cut  itself  should  be  made 
boldly,  and  deep  enough  to  reach  well  into  the  fat  of  the  ischio- 
rectal fossa.  The  forefinger  in  this  incision  will  readily  sepa- 
rate the  bowel  from  the  surrounding  tissue,  except  at  the  at- 
tachment of  the  levator  ani  muscle,  which  should  be  divided 
with  the  knife  or  scissors.  A  piece  of  sponge  is  pressed  into 
this  cut  to  restrain  the  bleeding,  while  the  opposite  side  is 
treated  in  the  same  way.  The  anterior  connections  give  more 
difficulty,  and  the  dissection  in  the  male  is  aided  by  having  a 
sound  in  the  urethra.  The  knife  and  scissors  replace  the  finger 
in  this  part  of  the  operation.  When  the  dissection  has  been 
carried  to  a  point  above  the  disease,  the  bowel  is  drawn  down 
and  held  while  the  wire  ecraseur  is  passed  over  it,  and  the  sec- 
tion made  at  the  required  level.  After  this  there  may  be  free 
but  seldom  serious  haemorrhage.  The  vessels  divided  in  the 
first  steps  of  the  operation  all  come  from  the  wall  of  the  bowel, 
and  if  ligatured  when  first  cut,  are  again  opened  with  the 
ecraseur. 

When  the  disease  is  located  to  one  side  of  the  bowel,  the 
operation  is  modified  accordingly.  The  preliminary  dorsal  cut 
is  the  same,  and  the  lateral  incision  is  made  on  the  affected  side. 
At  the  farther  end  of  this  lateral  incision,  away  from  the  dorsal 


350  DISEASES    OF    THE    KECTUM    AND    ANUS. 

one,  a  needle  carrying  a  cord  in  its  point  is  passed  around  the 
disease  and  into  the  rectum  above  it.  The  loop  of  cord  is 
brought  out  of  the  anus,  attached  to  the  chain  of  the  ecraseur, 
and  withdrawn  as  it  entered.  The  chain  is  then  made  to  cut  its 
way  out,  and  a  rectangular  piece  of  the  rectum  is  thus  included 
between  two  longitudinal  incisions,  one  posterior  with  the  knife 
and  one  lateral  with  the  chain.  In  this  rectangle  is  the  cancer, 
and  it  is  dissected  upward  from  below,  and  separated  above  by 
again  using  the  ecraseur. 

Instead  of  the  chain  or  wire  ecraseur,  the  wire  of  the  gal- 
vanic cautery  may  be  used,  heated  to  a  dull  red,  and  not  a 
white  heat,  if  the  desire  is  to  avoid  haemorrhage.  Or  again,  in- 
stead of  the  wire  the  galvanic  cautery  knife  may  be  used,  and 
the  operation  performed  with  bloodless  incisions.  This  is  the 
operation  favored  by  Verneuil.  The  rectum  is  first  divided  into 
lateral  halves  wTith  the  ecraseur,  as  in  the  method  of  Chassaig- 
nac,  the  cut  dividing  both  the  anterior  and  the  posterior  walls. 
Then  with  the  galvanic  cautery  blade  the  lateral  halves  are 
separated  from  their  attachments  stroke  by  stroke,  until  a  point 
is  reached  above  the  level  of  the  disease.  The  chain  is  again 
slipped  over  the  end  of  each,  and  the  final  section  made. 

An  ingenious  and  simple  method  applicable  to  certain  cases 
has  been  recorded  by  Emmet.1  The  growth  in  the  case  in  which 
it  was  used  was  an  epithelioma  the  size  of  a  hen's  egg,  situated 
on  the  posterior  wall  of  the  rectum  an  inch  above  the  sphincter, 
with  considerable  surrounding  infiltration.  The  sphincter  was 
stretched,  and  the  mass  seized  with  a  double  tenaculum  and 
drawn  well  down  by  an  assistant.  "  A  steel  groove  director,  as 
the  most  convenient  instrument  for  the  purpose,  was  pushed 
through  the  skin  in  front  of  the  coccyx  and  just  behind  the 
outer  edge  of  the  sphincter,  into  the  cellular  tissue  of  the  pelvis, 
and  then  made  to  puncture  the  rectum,  in  healthy  tissue,  just 
beyond  the  upper  edge  of  the  tumor.  The  end  was  turned  out 
of  the  gut,  and  pushed  far  enough  forward  to  rest  on  the  perin- 
eum while  the  other  end  was  over  the  coccyx.  Then  a  second 
director  was  pushed  around  from  the  outer  side  of  the  muscle 
on  one  side,  through  the  cellular  tissue  into  the  rectum,  across 
to  the  other  side,  through  the  cellular  tissue  and  skin  again  to 
the  opposite  side  of  the  muscle.     So  that  the  mass,  with  a  por- 


1  Principles  and  Practice  of  Gynaecology,  e'd.  1879. 


CANCER.  351 

tion  of  the  rectum  above,  was  now  brought  through  the  anus 
and  fixed  by  the  two  directors,  which  had  been  passed  behind 
the  mass  at  right  angles  to  each  other,  with  their  ends  resting 
outside  on  the  soft  parts.  The  chain  of  an  ecraseur  was  placed 
behind  these  two  instruments  and  slowly  tightened  till  the 
whole  mass,  as  transfixed,  was  cut  through  along  the  course  of 
the  directors.  By  this  means  I  removed  the  entire  sphincter 
muscle,  about  three  inches  of  the  posterior  wall  of  the  rectum, 
and  about  an  inch  and  a  half  of  the  rectal  surface  of  the  recto- 
vaginal septum.  The  immediate  result  was  a  most  formidable 
opening  in  the  connective  tissue  of  the  pelvis,  about  three 
inches  in  diameter,  and  cone-shaped  from  below.1' 

Dr.  Rouse  '  has  recently  called  attention  to  a  simple  method 
of  avoiding  a  wound  of  the  sphincter,  which  is  applicable  to 
some  of  the  slighter  cases.  A  curved  incision  is  made  parallel 
with  the  outer  border  of  the  sphincter,  and  on  a  line  with  its 
outer  limit.  By  introducing  the  finger  through  the  rectum,  the 
growth  may  be  everted  through  this  incision,  and  removed  with 
the  part  of  the  rectal  wall  to  which  it  is  adherent. 

Perhaps  the  best  of  all  the  operations  we  have  spoken  of  is 
the  combination  of  the  ecraseur  and  galvano-cautery  knife,  as 
used  by  Verneuil.  But  the  operator  is  at  liberty  to  choose 
from  among  them  all  the  one  he  considers  easiest  of  perform- 
ance, and  most  free  from  the  risk  of  haemorrhage  or  of  wound- 
ing surrounding  parts. 

A  wound  into  the  vagina,  though  always  to  be  avoided  when 
possible,  may  often  be  necessary  in  order  to  fully  remove  the 
disease.  When  the  fistula  thus  made  is  not  too  extensive,  it 
may  be  closed  immediately  after  the  operation.  If  large,  it 
must  be  left.  A  wound  of  the  urethra  in  the  male,  when  slight, 
is  to  be  treated  as  though  the  patient  had  submitted  to  an  ex- 
ternal urethrotomy,  by  the  frequent  passage  of  the  sound,  to 
prevent  contraction.  When  a  large  piece  has  been  taken  from 
the  urethral  wall,  a  permanent  recto-urethral  fistula  is  the  nec- 
essary result,  and  the  danger  of  fatal  inflammatory  action  is 
greatly  increased  from  the  presence  of  the  urine  in  the  rectal 
wound.  As  for  the  cases  reported  by  Nussbaum  and  others,  in 
which  the  whole  neck  of  the  bladder,  the  greater  part  of  the 
prostate,  and  the  seminal  vesicles  have  been  removed,  and  the 

1  Lancet,  October  2,  1880. 


352  DISEASES    OF    THE   RECTUM    AND    ANUS. 

patients  have  lived  for  years  in  comfort,  they  are  merely  curi- 
osities of  literature.  That  such  a  thing  may  happen  has  been 
proved,  but  that  the  operation  should  ever  be  undertaken  in  any 
case  where  such  a  result  is  necessary  for  the  entire  removal  of 
the  disease,  has  yet  to  be  proved. 

It  is  with  this  operation  much  the  same  as  with  proctotomy 
— by  trying  to  save  too  much,  discharge  is  impeded  and  life 
may  be  lost.  Cases  where  the  whole  of  the  sphincter  is  re- 
moved, together  with  the  skin  of  the  anus,  do  better  than  those 
in  which  an  attempt  is  made  to  save  the  sphincter  and  drain  the 
wound  with  drainage-tubes. 

The  operation  of  excision  has,  with  the  recent  advances  in 
abdominal  surgery,  also  been  applied  to  cancer  of  the  sigmoid 
flexure  and  descending  colon.  This  operation,  to  which  allusion 
has  already  been  made  and  to  which  Mr.  Marshall 1  has  very 
properly  applied  the  name  of  "  colectomy,"  has  now  assumed  a 
definite  place  in  surgery  and  marks  another  of  the  great  ad- 
vances of  the  present  century. 

It  dates  from  the  time  of  Reybard,  of  Lyons,2  who  in  1833  re- 
moved a  tumor  the  size  of  an  orange  from  the  sigmoid  flexure 
of  a  man  aged  twenty-eight  years.  In  this  case  the  tumor  could 
be  felt  through  the  abdominal  wall  in  the  left  iliac  fossa,  and 
the  incision  was  made  parallel  with  Poupart's  ligament  and  the 
crest  of  the  ilium.  The  tumor  was  drawn  out  through  this 
wound  and  excised  with  three  inches  of  the  adjoining  intestine. 
The  two  ends  of  the  bowel  were  stitched  together  and  replaced 
within  the  abdomen  and  the  abdominal  wound  was  completely 
closed.  There  was  considerable  local  trouble  for  a  few  days, 
but  on  the  thirty-eighth  day  the  wound  had  entirely  healed 
and  the  natural  passages  were  restored.  Death  occurred  ten 
months  after  from  recurrence  of  the  disease.  This  case  was 
subject  to  considerable  discussion  in  the  academy,  but  was 
finally  admitted  as  authentic. 

The  operation  thus  inaugurated  in  1833  has  been  modified  in 
two  essential  particulars  by  subsequent  operators,  one  in  the 
choice  of  location  of  the  incision,  the  other  in  the  subsequent 
disposal  of  the  ends  of  the  divided  intestine.  Since  the  first 
case  by  Reybard,  the  operation  has  been  performed  at  least 
seven  times. 

1  Clinical  Lecture  on  Colectomy,  Lancet,  May  6,  13,  1882. 

2  Bull,  de  l'Acad.  do  Med.,  vol.  is.,  1843-44. 


CANCER.  353 

Gussenbauer,  of  Liege,,  has  done  it  twice.  The  first  time,  in 
1877, '  was  upon  a  male  patient  aged  forty-two  years.  The  tu- 
mor, which  was  associated  with  the  usual  symptoms  of  obstruc- 
tion, could  be  felt  in  the  left  side,  but  an  attempt  was  made  to 
remove  it  through  an  incision  in  the  median  line  of  the  abdo- 
men. This  incision,  proving  insufficient,  was  enlarged  by  cut- 
ting laterally  as  far  as  the  lumbar  fascia.  Another  complica- 
tion arose  from  the  attachment  of  the  growth  to  the  small 
intestine,  which  was  opened,  and  faeces  were  allowed  to  escape 
into  the  peritoneal  cavity.  All  the  intestinal  wounds  were 
closed  with  sutures,  the  bowel  was  replaced  within  the  abdo- 
men, and  the  abdominal  incision  sewed  up.  In  this  case  death 
followed  in  fifteen  hours.  Gussenbauer's  second  case  was  per- 
formed in  1879, 2  and  there  had  been  no  return  of  the  disease 
two  years  later. 

Baum,  of  Dantzic,3  operated  between  these  two  dates  (1878) 
upon  a  male  patient,  aged  thirty-four  years,  in  a  case  of  doubt- 
ful nature.  He  first  opened  the  small  intestine  to  relieve  the 
symptoms  of  obstruction,  and  seven  days  later  he  discovered 
the  seat  of  the  obstruction  in  the  right  hypochondrium.  A 
second  operation  wTas  then  performed.  The  abdomen  was  again 
opened,  this  time  by  a  longitudinal  incision  over  the  tumor, 
two  and  a  half  inches  to  the  right  of  the  median  line,  and  this 
incision  was  afterward  enlarged  by  another  running  toward  the 
right.  The  growth  was  situated  at  the  junction  of  the  trans- 
verse with  the  ascending  colon,  and  was  removed,  together  with 
a  piece  of  the  mesentery  which  contained  an  enlarged  gland. 
The  divided  ends  of  the  bowel  were  invaginated  and  united,  the 
intestine  replaced,  and  the  abdominal  wound  closed.  There 
was  considerable  discharge  of  faeces  from  this  opening,  however, 
up  to  the  time  of  death  on  the  ninth  day. 

The  next  case  was  by  Martini,  of  Hamburg,*  in  1879,  and 
was  performed  with  the  deliberation  and  consequent  success 
which  arise  from  a  certainty  in  diagnosis  of  the  character  and 
location  of  the  tumor.  The  growth  was  situated  in  the  sig- 
moid flexure  and  could  be  felt  both  through  the  abdominal 
wall  and  the  rectum.     The  incision  was  made  over  the  tumor, 

1  Arch,  fur  klin.  Chirurg. ,  Bd.  xxiii. ,  1879. 
-  Ztschr.  fur  Heilk.,  Prag,  1880. 

3  Centralblstt  f  ur  Chir..  1879,  Bd.  ii.,  p.  169. 

4  Vierteljahrschrift  fur  Heilk.,  Bd.  i.,  1880. 
23 


354  DISEASES    OF   THE    RECTUM    AND    ANUS. 

the  intestine  below  was  cut  between  double  ligatures,  the  meso- 
colon was  divided  and  the  affected  glands  excised,  and  finally 
four  inches  of  the  bowel  were  excised  together  with  the  diseased 
mass  and  two  inches  breadth  of  mesocolon.  After  the  removal 
of  such  a  section  it  was  impossible  to  approximate  the  divided 
ends  of  intestine.  The  rectal  end  was,  therefore,  invaginated 
upon  itself,  closed  with  sutures  and  allowed  to  drop  into  the 
pelvis.  The  upper  extremity  was  attached  to  the  incision  in 
the  abdomen  to  form  an  artificial  anus.  There  were  no  bad 
symptoms,  and  in  a  few  weeks  the  man  was  able  to  return  to  his 
business. 

Czerny,  of  Heidelberg,  reported  the  next  successful  case  in 
I860,1  in  a  female  patient  aged  forty-seven  years.  In  this  case 
also  the  growth  could  be  felt  through  the  abdominal  wall  on  the 
left  side,  and  the  diagnosis  was  therefore  positive.  After  open- 
ing the  abdomen  over  the  tumor,  the  bowel  was  found  to  be  im- 
plicated at  two  points,  one  at  the  transverse  colon,  and  the 
other  at  the  sigmoid  flexure  which  curved  upward  to  an  abnor- 
mal degree  and  was  involved  in  the  same  disease  through  a  fold 
of  the  great  omentum.  Two  and  three-fourths  inches  of  the 
sigmoid  flexure,  and  four  inches  and  a  half  of  the  transverse 
colon  were  excised  and  the  cut  ends  of  each  portion  were 
united.  The  peritoneum  was  washed  out,  a  drainage-tube  in- 
serted, the  abdominal  incision  closed  except  for  the  drainage- 
tube,  and  the  whole  dressed  antiseptically.  For  a  time  there 
was  a  discharge  of  faeces  through  the  abdominal  wound,  but 
this  finally  closed  and  the  patient  was  well  in  four  months. 
The  return  of  the  disease  was,  however,  very  rapid,  and  death 
was  caused  by  it  in  about,  seven  months  after  the  operation. 

Billroth  operated  next  in  order,  in  1881, 2  on  a  male  patient 
twenty-eight  years  of  age.  The  operation  was  done  antisepti- 
cally, and  the  incision  was  the  usual  one  for  left  inguinal 
colotomy.  The  tumor  involved  the  lower  half  of  the  sigmoid 
flexure,  and  there  was  considerable  involvement  of  the  adjacent 
mesentery  and  of  the  tissue  behind  the  bowel.  The  upper  sec- 
tion of  the  bowel  was  used  for  the  formation  of  an  artificial 
anus.  The  patient  died  in  about  thirty-six,  hours  from  incipient 
diffuse  peritonitis. 

Bryant's  case'  is  next  in  order,  and  is  peculiar  in  the  fact 

'  Berliner  klin.  Woch.,  1880,  No.  45. 
'  Wien.  Med.  Wocb.,  March  5,  1881.  3  Lancet,  vol.  i.,  1882. 


CANCER.  355 

that  the  incision  was  the  usual  one  for  left  lumbar  colotomy. 
This,  in  fact,  was  the  operation  attempted,  but  after  the  bowel 
had  been  opened,  the  obstruction  was  found  to  be  above  the 
opening  made.  It  was  then  determined  to  excise  the  disease, 
and  this  was  successfully  done  through  the  original  incision. 
The  two  ends  of  the  bowel  were  attached  to  the  wound,  the 
upper  in  the  usual  manner  for  forming  an  artificial  anus.  The 
patient  recovered,  and  was  well  at  the  time  of  the  publication 
of  the  case.  The  disease  constituted  a  cylindrical  stricture  of 
limited  extent. 

The  patient  in  Mr.  Marshall's1  case  was  a  woman,  aged 
forty-nine  years,  and  no  positive  diagnosis  as  to  the  seat  of  the 
obstruction  could  be  made.  The  difficulties  attending  the  diag- 
nosis may  best  be  gathered  from  his  own  description. 

"  The  wasting  and  rapid  ageing  of  the  patient,  although  she 
took  food  tolerably  well,  suggested  the  presence  of  a  malignant 
stricture,  probably  epitheliomatous  ;  but  it  was  difficult  to  say 
how  far  the  symptoms  were  referable  merely  to  the  pain  and 
vomiting  which  she  had  suffered  ;  but  whatever  the  nature  of 
the  obstruction,  its  seat  was  obscure.  The  chronicity  of  the 
case  pointed  strongly  to  the  large  intestine,  but  the  abdomen 
was  not  broad  in  shape  ;  no  tumor  or  scybala  could  be  felt  in 
either  iliac  fossa,  or  elsewhere  along  the  course  of  the  large  gut, 
though  both  fossae  could  be  well  examined  under  chloroform. 
There  was  no  dulness  in  either  loin  to  indicate  a  full  colon,  and 
no  "colonic"  note  to  show  that  the  bowel  contained  gas. 
Rectal  examination  revealed  nothing.  The  long  tube  passed 
one  foot,  and  an  enema  of  three  pints  was  easily  given,  and 
seemed,  from  an  accompanying  diminution  of  resonance  in  the 
left  flank,  to  have  entered  the  descending  colon.  But  as  the 
patient  was  lying  on  the  left  side,  it  was  possible  that  fluid 
contents  had  gravitated  into  the  small  intestines  lying  over  the 
descending  colon — a  source  of  movable  dulness  which,  as  re- 
marked by  Mr.  Boyd,  is  often  overlooked.  The  amount  and 
uniformity  o£  the  abdominal  distention  were  sufficient  to  prove 
that  the  obstruction,  if  in  the  small  intestine,  was  near  the 
lower  end.  If,  however,  the  suspicion  were  correct  that  the 
cause  of  the  obstruction  was  an  epithelioma,  the  probability  of 
its  seat  being  in  the  large  intestine,  somewhere  beyond  the 
caecum,  was  greatly  increased." 

1  Lancet,  May  6,  13,  1882. 


356  DISEASES    OF   THE    RECTUM    AND    ANUS. 

On  account  of  the  uncertainty  in  diagnosis,  the  incision  in 
this  case  was  an  exploratory  one  in  the  median  line,  and  the 
growth  was  found  in  the  descending  colon,  between  the  lower 
end  of  the  kidney  and  the  iliac  crest.  As  it  was  impossible  to 
bring  this  part  of  the  bowel  to  the  median  line,  the  first  incision 
was  abandoned,  and  a  second  one  made  over  the  tumor,  parallel 
with  the  last  rib,  and  one  inch  and  a  half  above  the  posterior 
part  of  the  iliac  crest.  The  growth  was  cut  out  with  the  scissors, 
together  with  an  inch  of  the  bowel  above  and  below,  between 
double  ligatures.  The  open  end  of  the  upper  section  of  the 
bowel  was  attached  to  the  abdominal  wound  to  form  an  arti- 
ficial anus,  and  the  lower  end  was  left  projecting  from  the 
lower  and  hinder  part  of  the  wound  with  the  strong  catgut 
ligature  drawn  tight  upon  it.  The  patient  died  of  peritonitis  on 
the  third  day. 

The  latest  case  is  that  reported  by  Lammiman.1 
The  patient,  a  woman  aged  fifty-four,  though  in  good  condi- 
tion when  the  signs  of  obstruction  first  showed  themselves,  ob- 
stinately refused  to  have  any  operation  performed  until  she  had 
passed  seventeen  days  without  nourishment  by  the  stomach. 
The  usual  incision  was  made  on  the  left  side.  The  writer  says  : 
"I  dissected,  as  quickly  as  possible,  down  to  the  fascia  trans- 
versalis,  but  having  to  deal  with  very  free  haemorrhage,  ray 
progress  was  somewhat  slow,  as  I  had  to  tie  many  vessels  as  I 
went  on.  Then,  having  cleared  the  fascia  through  the  whole 
length  of  the  wound  from  muscle  and  fat,  I  divided  the  fascia 
trans versalis  upon  the  director  and  my  forefinger.  Now,  hav- 
ing scraped  away  a  large  quantity  of  sub-colic  fat,  I  came  upon 
the  intestine,  not  a  distended  but  a  collapsed  one,  and  speedily 
found  the  stricture  itself  just  at  the  bottom  of  my  incision,  now 
some  inches  deep.  My  colleagues  assisted  me  in  raising  the 
gut  to  the  surface,  but  it  was  not  an  easy  matter,  for  it  did  not 
leave  its  bed  as  I  had  hoped  it  would ;  it  required  much  pa- 
tience and  gentle  force  to  accomplish  this.  At  last,  having 
freed  enough  of  it,  I  opened  the  intestine  above  the  stricture, 
fastened  it  to  the  skin,  and  having  placed  a  very  stout  ligature 
of  carbolized  catgut  around  the  gut  below  the  stricture,  I  cut 
the  latter  completely  away.  Having  to  our  satisfaction  con- 
cluded that  all  haemorrhage  had  ceased,  I  cut  off  the  ends  of 
the  ligature  short,  and  returned  it  into  the  abdominal  cavity 

1  The  Lancet,  August  4,  1883. 


CANCER.  357 

with  the  lower  end  of  the  intestine,  fastened  up  as  much  as 
seemed  necessary  of  the  wound,  and  placed  the  patient  in  bed." 

In  the  course  of  an  hour  or  two  a  large  amount  of  fsecal 
matter  passed  through  the  wound,  but  the  patient  was  so  weak 
from  her  starvation  that  it  required  several  hours  to  rally  her 
from  the  operation,  and  she  sank  and  died  forty-eight  hours 
later.     The  disease  was  scirrhus.1 

Of  these  ten  cases  five  have  been  immediately  fatal  from  the 
operation  itself,  and  live  have  recovered.  Of  these  latter  one 
died  in  seven  months,  one  in  ten  months,  one  was  alive  two 
years  later,  the  history  of  one  ends  with  the  recovery  from  the 
operation,  and  Mr.  Biyant's  was  alive  at  the  .time  the  case  was 
published. 

In  deciding  upon  the  propriety  of  interference  in  any  partic- 
ular case,  it  would  seem  advisable  to  consider  how  long  a  life 
the  patient  is  likely  to  have  if  not  operated  upon.  For  exam- 
ple, it  would  hardly  seem  good  surgery  to  subject  a  patient  to 
an  operation  the  mortality  of  which  is  fifty  per  cent.,  and  then 
have  him  die  of  a  recurrence  in  seven  months,  when  he  might 
have  lived  seven  months  without  an  operation.  The  amount  of 
actual  obstruction  caused  by  the  disease  must  in  many  cases 
decide  the  propriety  of  surgical  interference.  Within  a  few 
months  I  have  found  it  necessary  to  decide  this  question  in  the 
case  of  a  personal  friend,  a  man  whose  every  day  of  life  was 
important  both  for  himself  and  family.  The  diagnosis  seemed 
plain,  the  man  was  in  good  condition  for  operation,  and  in  many 
respects  the  case  seemed  favorable  for  excision.  But  there  was 
little  or  no  actual  obstruction,'  the  constitutional  disturbance 
was  great,  while  the  local  difficulty  was  slight ;  I  feared  that  the 
growth  which  could  be  felt  through  the  abdomen  was  so  diffused 
as  to  make  the  excision  of  other  parts  than  mere  intestine  a 
probable  necessity,  and  there  seemed  little  to  be  gained  and 
much  to  be  lost  by  operation. 

As  pointed  out  by  Marshall  in  his  instructive  resume  of  the 
operation,  the  result  undoubtedly  depends  in  a  great  degree 
upon  the  certainty  with  which  the  diagnosis  is  made,  or,  in 
other  words,  upon  the  exact  adaptation  of  the  operation  to  the 

1  A  peculiar  case  of  excision  has  been  reported  by  Nicolaysen  (Nordiskt,  Medi- 
cinskt  Arkiv.,  1882).  A  cancer  of  the  descending  colon  became  invaginated  into  the 
rectum,  was  pulled  through  the  anus,  and  cut  off.  The  patient  recovered,  and  there 
was  no  return  for  two  and  a  half  months. 


358  DISEASES    OF    THE    RECTUM    AND    ANUS. 

end  to  be  attained.  In  most  of  the  successful  cases,  the  diag- 
nosis as  to  the  seat  of  the  obstruction  was  made  before  the 
operation  was  begun,  and  in  all  of  them  only  a  single  incision 
was  necessary  to  reach  the  tumor.  In  three  of  the  four  fatal 
cases,  two  incisions  were  made — one  in  the  median  line,  and, 
subsequently,  another  to  reach  the  disease.  In  this  way  the 
severity  of  the  procedure  was  greatly  increased. 

There  seems  to  be  little  difference  in  the  mortality  whether 
the  ends  of  the  divided  intestine  be  united  and  the  abdominal 
wound  closed,  or  one  end  be  brought  to  the  surface  for  the 
formation  of  an  artificial  anus.  The  latter  is  the  simpler  pro- 
cedure ;  the  former,  when  successful,  gives  the  better  result. 
A  great  difference  in  the  size  of  the  two  ends  will  sometimes 
render  their  union  difficult ;  the  upper  one  being  frequently 
hypertrophied  and  dilated,  and  the  lower  contracted. 

The  study  of  these  cases  leads  plainly  to  the  following  con- 
clusions : — 

1.  In  cancer  of  the  descending  colon,  sigmoid  flexure,  and 
upper  part  of  the  rectum,  when  the  disease  is  still  movable,  an 
attempt  at  its  removal  through  the  abdominal  wall  is  justifiable. 

2.  In  cases  of  obstruction  where  the  symptoms  point  toward 
this  part  of  the  bowel  as  the  affected  part,  even  when  the  diag- 
nosis is  not  certain,  it  may  be  well  to  make  the  exploratory  in- 
cision in  the  left  groin  instead  of  in  the  median  line,  having  in 
mind  the  possible  extirpation  of  the  disease  and  the  formation 
of  an  artificial  anus. 

3.  In  cases  of  intended  colotomy,  also,  it  may  be  found  pos- 
sible, after  the  incision  has  been  made,  to  substitute  colectomy, 
and  this  constitutes  another  reason  for  choosing  the  inguinal 
to  the  lumbar  incision  in  that  operation,  though,  as  in  Bryant's 
case,  colectomy  may  be  done  through  the  loin. 

4.  The  operation  of  colectomy  compares  very  favorably  with 
colotomy  in  malignant  disease,  and  while  the  latter  may  be  the 
more  suitable  in  an  advanced  case,  the  former  may  give  better 
results  when  the  disease  is  in  its  incipiency. 

The  palliative  treatment  of  malignant  stricture  of  the  rectum 
is  in  many  points  the  same  as  of  non-malignant.  The  relief  of 
pain  is  perhaps  a  more  marked  indication  in  most  cases.  The 
juiiii  depends  on  two  classes  of  causes— those  which  make  cancer 
a  painful  disease  wherever  met  with  in  the  body,  and  those 
which  are  due  solely  to  its  situation  at  the  outlet  of  the  bowel. 


CANCER.  359 

Among  the  first,  we  liave  pressure  upon  adjacent  parts  and  in- 
volvement of  neighboring  organs  and  nerves  ;  and  among  the 
second,  the  passage  of  faeces  over  an  ulcerated  surface  and 
spasm  of  the  sphincter  muscle  from  irritation  caused  by  its 
direct  implication  in  the  cancerous  growth,  or  by  the  passage 
over  it  of  irritating  sanious  discharges  from  the  sore.  From 
this  it  is  easy  to  understand  why  cancer  is  in  one  person  at- 
tended by  excruciating  suffering,  while  another  may  hardly  be 
conscious  of  its  presence  ;  and  why  the  pain  is  in  some  paroxys- 
mal and  particularly  aggravated  by  a  movement  of  the  bowels, 
and  in  others  dull  and  constant,  radiating  through  the  loins 
and  down  the  thighs.  For  the  relief  of  this  symptom  we  have 
at  our  command  :  a.  Regulation  of  the  passages,  diet,  and  the 
recumbent  posture  ;  b.  Anodynes  locally  and  by  the  mouth  ;  c. 
Partial  destruction  of  the  growth  by  means  of  the  curette, 
cauterization,  or  partial  extirpation ;  d.  Division  of  the  sphinc- 
ter ;  e.  Lumbar  colotomy. 

The  passages  should  be  kept  soft  but  not  fluid,  as  any  ap- 
proach to  diarrhoea  always  aggravates  the  suffering.  This  may 
be  done  partly  by  the  choice  of  food,  which  needs  to  be  reg- 
ulated with  great  care  on  account  of  the  tendency  to  gastric 
disturbance,  more  or  less  of  which  is  always  present ;  and  by 
the  administration  of  the  mineral  waters,  which  are  generally 
suflicientry  laxative  for  the  purpose.  Rest  in  the  recumbent 
posture  is  a  means  of  palliation  of  great  value,  sometimes  giving 
more  relief  than  anodynes.  These  latter  may  be  given  both  by 
the  mouth  and  in  enemata,  and  if  possible  should  be  pushed  to 
the  point  of  relieving  suffering.  This  seems  so  plain  a  duty 
which  the  surgeon  owes  to  his  patient,  that  we  need  not  stop  to 
discuss  any  possible  moral  bearing  it  may  have.  If  the  agony 
of  this  incurable  malady  could  always  be  relieved  by  the  ad- 
ministration of  opium,  the  question  of  operative  interference 
would  arise  much  less  frequently  than  it  now  does.  But,  un- 
fortunately, the  constant  administration  of  this  or  any  other 
narcotic  will  sometimes  cause  gastric  and  mental  disturbance, 
harder  to  bear  than  the  disease.  By  using  the  finger-nail,  a 
curette  similar  to  the  one  used  in  the  uterus,  or  a  scoop  such  as 
is  used  for  submucous  uterine  tumors,  the  pain  may  in  some 
cases  be  greatly  relieved  by  a  removal  of  a  part  of  the  growth 
when  of  the  soft  variety.  The  same  may  be  done  by  the  appli- 
cation of  chemically  destructive  agents  or  the  actual  cautery, 


360  DISEASES    OF   THE    RECTUM    AND    ANUS. 

and  even  b}r  the  partial  excision  of  the  mass,  merely  as  a  means 
of  relief  and  where  there  is  no  question  of  cure.  I  have  already 
called  attention  to  division  of  the  sphincter  muscle  as  a  pallia- 
tive measure  in  the  treatment  of  rectal  disease,  and  all  that  was 
said  regarding  the  treatment  of  benign  stricture  applies  equally 
well  to  cancer. 

The  dernier  res  sort  of  surgery  for  the  relief  of  pain  is  lumbar 
colotomy.  We  have  already  attempted  to  limit  the  scope  of 
this  operation.  In  any  case  in  which  the  suffering  is  due  to  the 
direct  contact  of  faeces  with  the  diseased  surface,  and  is  not  due 
to  a  spasmodic  action  of  the  sphincter  muscle,  and  cannot 
therefore  be  relieved  by  the  permanent  division  and  paralysis 
of  that  muscle,  and  is  not  due  to  the  extension  into  and  press- 
ure of  the  disease  upon  neighboring  parts,  the  operation  may 
be  tried.  There  may  be  such  cases,  but  they  are  not  common — 
not  nearly  as  common  as  is  lumbar  colotomy  for  cancer.  Let  it 
be  remembered,  however,  that  after  colotomy  faeces  will  still 
find  their  way  to  the  tender  point,  and  that  the  amount  of 
suffering  from  a  small  mass  of  faeces  may  be  as  great  as  from 
the  entire  quantity. 

"With  regard  to  husbanding  the  sufferer's  powers  and  prolong- 
ing life,  much  may  be  done  by  careful  nursing  and  medication. 
Milk  is  by  far  the  best  diet,  and  cod-liver  oil  in  small  doses 
the  best  medicine  where  it  can  be  borne,  for  it  has  a  laxative  as 
well  as  a  tonic  action.  Cleanliness  is  best  obtained  b}^  frequent 
washing  out  of  the  rectum  with  disinfecting  fluids,  as  perman- 
ganate of  potash,  carbolic  acid,  and  chloral. 

The  means  of  overcoming  obstruction  in  malignant  disease 
are  also  much  the  same  as  in  benign  stricture,  and  to  what  has 
already  been  said  on  that  subject  we  must  again  refer  the 
reader.  Before  commencing  to  treat  the  obstruction  as  such, 
it  is  well  to  remember  that  an  exceedingly  small  outlet  to  the 
alimentary  canal  may,  with  proper  care,  be  made  to  answer  all 
the  calls  oC  nature.  We  see  this  constantly  in  cases  of  stricture, 
both  simple  and  malignant,  where  the  finger  cannot  be  forced 
through  the  obstruction,  and  yet  there  is  no  retention  ;  and  in 
such  cases,  by  the  judicious  administration  of  laxatives,  life 
may  be  made  so  comfortable  that  the  question  of  surgical  inter- 
ference shall  be  postponed  indefinitely.  AVhen,  however,  ob- 
struction is  actually  threatened,  much  may  be  done  by  the 
medical  means  already  pointed  out. 


CANCER.  361 

When  dilatation  becomes  necessary,  it  should  be  of  the 
gentlest  kind.  The  cases  of  fatal  accident  from  perforation  of 
the  bowel  where  the  coats  have  been  weakened  by  ulceration 
are  already  numerous  enough  to  serve  as  warnings  for  all  future 
time.  The  best  of  all  dilators  in  cancerous  disease  is  the  finger, 
either  that  of  the  patient  or  the  nurse,  passed  daily,  and  none 
of  the  mechanical  means  with  which  we  are  acquainted  equals 
this  for  safety  and  comfort. 

When  the  disease  is  beyond  the  reach  of  the  finger,  a  bougie 
must  be  used,  but  the  dangers  are  greatly  increased,  and  it 
may  be  better  at  once  to  make  an  artificial  anus  than  to  incur 
the  risk  of  fatal  accident  which  the  use  of  a  bougie  high  up  the 
bowel  certainly  entails.  The  frequency  with  which  the  bougie 
may  be  used  will  depend  upon  the  result  of  its  trial.  Should 
much  irritation,  tenesmus,  or  haemorrhage  follow  its  employ- 
ment, the  patient  will  soon  refuse  to  submit  to  its  continuance  ; 
while,  on  the  other  hand,  should  the  result  be  favorable,  it  may 
be  employed  daily.  The  softest  bougie  is  the  best,  and  a  candle 
often  answers  admirably. 

If  dilatation  be  found  too  painful  or  ineffectual,  as  it  some- 
times will,  recourse  may  be  had  to  division  or  partial  destruc- 
tion of  the  cancerous  mass.  A  double  proctotomy  maybe  done 
in  case  of  malignant  disease,  and  the  section  of  the  growth  be- 
tween the  two  incisions  be  removed,  in  this  way  opening  once 
more  the  calibre  of  the  bowel  and  overcoming  the  obstruction. 
I  have  performed  this  modified  operation  with  great  relief,  and 
I  have  also  found  that,  after  making  a  single  free  division  of 
the  cancerous  mass,  large  pieces  adjacent  to  the  cut  could  be 
excised  with  great  facility  and  without  danger.  The  latter 
operation  is  rather  the  preferable  one. 

Relief  both  to  pain  and  obstruction  may  sometimes  be  gained 
in  this  way  by  a  partial  destruction  and  extirpation  of  a  cancer- 
ous growth,  where  its  entire  removal  is  out  of  the  question,  and 
its  local  return  may  be  expected  with  certainty.  By  such 
measures  the  evacuations  may  be  made  less  painful,  the  spas- 
modic action  of  the  sphincter  and  the  rectal  tenesmus  may  be 
allayed,  the  cancerous  look  may  for  a  time  disappear,  and  the 
patient  recover  sufficient  strength  to  resume  the  ordinary  occu- 
pations of  life.  I  have  seen  as  good  results  follow  this  opera- 
tion as  ever  follow  colotomy. 

A  growth  may  be  attacked  in   this  way,  either  with   the 


302  DISEASES    OF    THE    RECTUM    AXD    ANUS. 

knife,  cautery,  linger,  or  curette.  I  have  been  exceedingly  well 
satisfied  in  several  cases  with  a  modified  operation,  which  con- 
sists in  first  dividing  the  stricture  posteriorly,  together  with  the 
parts  between  the  disease  and  the  skin,  with  the  cautery  knife, 
next  removing  considerable  portions,  if  they  could  be  isolated, 
with  the  wire  ecraseur  (Fig.  85),  and  finally  resorting  to  the 
sharp  scoop  of  Simon  (Fig.  86.)  By  these  means  combined  a 
large  portion  of  the  disease  may  be  removed,  the  lumen  of  the 


Fig.  85. — Wire  Ecraseur. 


bowel  may  be  almost  completely  re-established,  and  yet  the 
patient  is  spared  the  risk  of  a  complete  extirpation,  as  well  as 
the  objectionable  artificial  anus.  In  only  one  such  case  have  I 
experienced  any  trouble  from  this  operation,  and  in  that  one  the 
patient  nearly  died  of  secondary  haemorrhage  on  the  tenth  day 
— about  the  time  of  the  separation  of  the  extensive  sloughs 
caused  by  the  free  application  of  the  cautery. 

Caustic  applications  are  of  no  use,  except  in  cases  where  a 
fungous  mass  has  protruded  from  the  anus.  This  may,  at 
times,  be  removed,  with  great  advantage  to  the  sufferer,  by  the 
application  of  a  paste  of  arsenite  of  copper,  mixed  with  mucil- 


G.TIEMAN.J  &C0 

Fig.  86. — Simon's  Sharp  Scoop. 


age.  The  operations  for  removing  a  part  of  the  growth  with  the 
finger,  scoop,  or  curette  may  give  great  relief  in  the  soft  varie- 
ties of  the  disease.  The  sphincter  should  first  be  thoroughly 
dilated,  the  anus  held  open  with  a  speculum,  and  as  much  of 
the  diseased  tissue  as  possible  torn  and  scraped  away.  Ha3m- 
orrhage,  of  course,  is  to  be  expected,  but  this  is  less  where  the 
growth  is  boldly  attacked  in  its  deeper  parts,  than  when  the 
surgeon  is  timid  and   attacks  merely  the  superficial  portions, 


CANCER.  363 

and  may  be  controlled  either  by  plugging  the  wound  with  lint 
and  styptics,  or  by  the  actual  cautery.  Allingham  relates  a 
case  in  which  he  entirely  enucleated  an  immense  encephaloid 
with  his  hand,  with  the  happiest  results. 

As  a  substitute  for  partial  destruction  of  the  growth  in  this 
way,  the  operation  of  crushing  with  an  instrument  similar  to 
the  enterotome  of  Dupuytren  has  been  proposed.  The  proceed- 
ing is  only  applicable  to  a  certain  class  of  cases,  in  which  the 
stricture  is  anular  and  not  too  extensive  to  be  grasped  by  the 
instrument,  and  has  no  advantages  over  the  other  methods. 

There  is  no  obstruction  within  four  inches  of  the  anus  which 
may  not  be  overcome  by  some  one  or  other  of  these  means. 
What,  then,  remains  for  lumbar  colotomy?  Simply  those 
above  the  reflection  of  the  peritoneum. 

It  will  often  be  difficult  for  the  surgeon  to  decide  for  or 
against  colotomy  in  these  cases.  Two  factors  enter  into  the 
question  :  1st,  Whether  or  not  the  patient  is  likely  to  survive  the 
operation  itself  ;  and,  2d,  if  this  is  decided  in  the  affirmative, 
whether  sufficient  is  to  be  gained  to  pay  for  the  risk.  The  gen- 
eral condition  of  the  patient,  the  extent  of  disease  as  regards 
secondary  deposits,  and  the  amount  of  pain  due  to  defecation, 
all  have  to  be  taken  into  consideration.  The  operation  may  be 
indicated  to  relieve  this  pain  when  there  is  not  much  chance  of 
actually  prolonging  life,  and  it  may  be  indicated  to  prevent  or 
overcome  obstruction  where  there  is  no  great  amount  of  pain, 
lam  inclined,  for  myself,  to  limit  the  operation  to  those  cases 
where  the  pain  of  defecation  is  great,  and  where  the  disease  is 
still  circumscribed,  and  should  not  for  the  choice  between  death 
from  obstruction  and  death  a  few  weeks  later  from  exhaustion 
always  have  recourse  to  this  extreme  measure,  but  should 
rather  trust  to  securing  a  comparatively  easy  passing  away  of 
the  patient  under  the  influence  of  opium.  Indeed,  many 
patients  will  decide  the  question  in  this  way  for  themselves 
when  it  is  explained  to  them  in  all  its  bearings. 

It  is  a  curious  fact  that,  by  relieving  the  over-distention  of 
the  bowels  by  colotomy,  the  obstruction  also  will  sometimes 
cease,  and  passages  will  again  pursue  their  natural  course. 
Such  a  case  is  reported  by  Goodhart,  where  three  successive 
operations  for  opening  the  colon  above  the.  stricture  were  re- 
sorted to  to  relieve  obstruction,  and  after  each  one  the  passages 
were  again  restored  to  the  natural  outlet. 


CHAPTER   XIII. 

IMPACTED   F-El'ES   AKD   FOREIGN   EODIES. 

Impacted  Faeces. — Intestinal  CkmcxetifHia — Diagnosis  and  Treatment  of  Impaction. — 

Foreign  Bodies  Swallowed. — Results  which  may  Follow  the  Swallowing  of  a  For- 
eign Body. — Ulceration  and  Abscess. — Foreign  Bodies  Introduced  per  Anum. — 
Ca-es. — Prognosis. — Treatment. — Dangers  of  Attempts  at  Removal. — Laparotomy 
for  Removal. — Cases  successful. 

Impaction  of  Faces. — The  impaction  of  f feces  may  be  due  to 
several  causes,  but  is  most  generally  a  symptom  either  of  in- 
testinal atony  in  old  some  paralytic  affection  such 
as  locomotor  ataxia.  It  not  infrequently  occurs  in  women  as  a 
result  of  the  entire  neglect  of  the  function  of  defecation,  for 
which  they  are  perhaps  unjustly  celebrated  ;  and  it  may  follow 
a  partial  paralysis  of  the  rectum  from  the  long-continued  use 
of  large  enemata.  or  the  pressure  of  the  total  head  in  child- 
birth. It  may  also  result  as  a  consequence  of  a  painful  affec- 
tion, such  as  a  fissure,  which  renders  each  act  of  defecation  an 
agony  to  be  avoided  by  every  possible  means.  The  disease  is 
generally  one  of  old  people,  of  hysterical  girls,  and  of  ca: 
women;  but  it  has  I  a  in  children,  and  as  a  result  of  im- 
proper diet  may  occasionally  be  encountered  in  young  and 
healthy  men. 

Intestinal  concretions  may  be  composed  entirely  of  hardened 
and  stratified  or  clayey  masses  of  feces,  or  they  may  contain 
within  them  as  a  nucleus  a  biliary  calculus,  or  indigestible 
Bnbstances  which  have  been  hastily  swallowed,  such  as  peach- 
pits,  cherry-sl  oes,  etc.  Molliere  rails  attention  to  the  pres- 
ence of  magnesia,  which  favors  the  aggregation  of  frecal  mat- 
ters, and  which  also  may  act  as  the  nucleus  of  a  scybalus  :  and 
the  frequency  of  impaction  during  the  famine  in  Ireland  in 
1846,  when  potatoes,  and  those  of  a  very  poor  quality,  were  the 


IMPACTED    FAECES    AND    FOREIGN    BODIES.  365 

only  article  of  diet,  is  a  well-known  historical  fact.1  In  Scot- 
land, where  oatmeal  is  a  favorite  article  of  diet,  fsecal  accumu- 
lations are  said  to  be  of  frequent  occurrence.  Certain  other 
drugs  besides  magnesia,  such  as  chalk,  sulphur,  and  powdered 
cubebs,  have  been  blamed  as  the  cause  of  intestinal  concretions. 
Intestinal  calculi  have  been  seen  which  were  composed  of  pure 
cholesterin,  or  of  a  biliary  calculus  coated  with  cholesterin. 

The  usual  location  of  a  mass  of  impacted  faeces  is  the  rectal 
pouch,  but  it  may  be  situated  anywhere  between  the  caecum 
and  this  point.  The  symptoms  to  which  it  gives  rise  are  gener- 
ally sufficiently  well  marked  to  enable  the  practitioner  to  reach 
a  correct  diagnosis  if  he  be  on  his  guard.  The  pains  which  it 
causes  will  generally  be  obscure  and  may  be  located  anywhere 
in  the  abdomen  or  in  the  lower  extremities  ;  and  the  signs  of 
disturbance  in  digestion  are  not  in  themselves  sufficiently  marked 
for  diagnosis,  but  the  one  symptom  which  is  characteristic  is 
diarrhoea. 

Just  as  the  practitioner  has  to  learn  that  incontinence  of 
urine  may  be  a  sign  of  a  distended  and  not  an  empty  bladder, 
so  he  may  have  to  learn  by  a  disagreeable  error  in  diagnosis 
that  a  diarrhoea  is  sometimes  a  result  of  an  overfilled  and  ob- 
structed rectum.  This  diarrhoea  is  peculiarly  foetid  in  charac- 
ter, and  the  matters  discharged  may  be  entirely  free  from  faeces 
and  consist  entirely  of  mucus.  In  some  cases  there  may  be  an 
approach  to  a  daily  natural  evacuation.  The  act  of  defecation 
is  always  attended  by  straining  and  pain  as  the  faecal  ball  is 
pressed  down  against  the  perinaeum  and  rises  again  when  the 
muscular  effort  ceases.  To  these  symptoms  Allingham  adds  a 
peculiar  ringing,  barking  cough,  morning  vomiting  (particularly 
in  women),  and  night-sweats. 

Of  course  errors  in  diagnosis  are  easy  in  such  a  condition  as 
this,  and  a  mass  of  faeces  in  the  colon  may  be  mistaken  for  any 
and  every  sort  of  tumor  in  the  pelvis  or  abdomen.  Liver, 
spleen,  stomach,  uterus,  and  ovaries  have  again  and  again  been 
supposed  diseased  in  these  cases  when  a  simple  digital  exam- 
ination of  the  rectum,  or  in  women  even  of  the  vagina,  could 
not  fail  to  make  the  diagnosis  clear.  Unfortunately  for  diag- 
nosis, the  general  practitioner  is  not  fond  of  making  rectal 
examinations,  and  these  cases  are  not  infrequently  treated  with 
bismuth  and  opium  as  a  consequence. 

1  For  description  of  these  cases  see  article  by  Dr.  Papham  in  the  Lancet,  1850. 


366  DISEASES    OF   THE    RECTUM    AND    ANUS. 

The  following  instructive  case  was  reported  by  Dr. 'Griffith.1 

In  the  autumn  of  1876  I  was  hurriedly  summoned  to  an  old 
lady,  who  had  within  a  few  days  of  my  seeing  her  met  with  a 
severe  accident  in  the  city,  having  been  knocked  down  by  a 
hansom  as  she  was  crossing  the  street.  All  her  friends  had 
given  her  up  to  die.  She  was  so  powerless  to  move,  so  pros- 
trated, and  so  large  a  tumor,  they  stated  to  me,  had  made  its 
appearance  since  her  injuries.  Her  age  (eight}*)  seemed  to  ex- 
clude all  hope  of  recovery  ;  and  I  was  asked  to  see  her — more 
that  it  should  not  be  said  she  had  died  incapable  of  making 
her  will  and  to  witness  her  signature  to  it,  than  with  any 
idea  that  I  could  benefit  her. 

I  examined  the  abdomen,  and  while  doing  so  learned  from 
her  that  she  thought  she  had  been  larger  on  the  left  side  for 
some  time  before  the  accident.  I  found  considerable  enlarge- 
ment of  the  entire  abdomen  from  flatulent  distention,  and  on 
the  right  side  a  tumor,  hard  and  apparently  irregular,  extend- 
ing from  the  left  hypochondriac  into  the  left  iliac  fossa,  and 
passing  a  little  way  to  the  right  of  the  median  line.  At  first,  I 
thought  it  might  be  enlarged  spleen,  or  a  left  ovarian  dropsy, 
or  an  extrauterine  fibroid,  which  had  been  unnoticed,  and  was 
now  observed  solely  because  attention  was  directed  to  the  left 
side,  where  the  patient  had  been  struck  by  the  vehicle.  I  could 
not  at  this,  my  first  visit,  make  a  veiy  minute  examination, 
owing  to  the  extreme  prostration  and  depression  ;  but  at  my 
second  visit,  having  in  the  interval  built  her  up  and  cheered  her 
all  I  could,  I  examined  very  carefully  per  vaginam,  and  with 
equal  care  explored  by  the  rectum.  I  then  came  to  the  conclu- 
sion that  there  was  neither  ovarian  nor  uterine  tumors,  and  that 
I  had  to  deal  with  an  accumulation  of  faeces — even  though  the 
bowels  were  moved  every  day,  as  the  attendant  informed  me, 
and  that  the  accumulation  had  commenced  previous  to  her  acci- 
dent ;  forming,  no  doubt,  the  enlargement  which  she  told  me 
she  had  noticed  before  her  injury,  and  which,  as  the  accumula- 
tion increased,  culminated  in  the  enlargement  I  found.  I  swept 
out  the  bowels  by  free  purgation,  kept  up  for  some  days,  while 
I  sustained  her  with  light  and  easily  digested  nutrients,  allow- 
ing as  stimulant  only  good  tea  and  coffee. 

The  next  case  is  also  from  the  same  author  : 

1  Faecal  Accumulations  Stimulating  Utero-Ovarian  Tumors.     Edinburgh  Medical 
Journal,  May,  1877. 


IMPACTED    F^CES    AND    FOEEIGN    BODIES.  367 

Mrs.  G ,  aged  twenty-five,  mother  of  three  children  ;  the 

last  being  about  four  months  old  when  I  was  first  in  attendance. 
I  was  called  up  to  her  on  the  night  of  June  18,  1876,  "as  she 
was  suffering  acute  pain  in  the  left  side,  which  she  could  endure 
no  longer."  On  examining  the  abdomen,  I  found  a  hard,  irreg- 
ular, exceedingly  tender  tumor,  from  which  she  was  enduring 
great  agony,  and  which  was  almost  as  large  as  an  infant's  head. 
I  made  no  further  examination  that  night,  contenting  myself 
with  ordering  her  one-half  grain  morphia  suppositories,  to  re- 
lieve not  only  the  pain,  but  likewise  the  tenesmus  and  the 
passing  of  mucus.  The  discharge  from  the  bowels  was  quite 
fluid,  but  distinctly  fffical,  occasionally  a  scybalous  mass  mak- 
ing its  appearance. 

Next  day,  the  morphia  having  taken  good  effect,  I  examined 
with  the  finger  by  the  vagina,  but  could  make  out  neither 
ovarian  nor  uterine  tumor ;  the  sound  in  utero  enabled  me  to 
make  certain  that  there  was  no  intrauterine  growth  ;  but  move- 
ment of  the  uterus  with  the  sound  in  the  interior  of  it  was  at- 
tended with  the  movement  of  the  mass,  which  I  found  lay  out- 
side the  womb,  yet  connected  to  the  left  and  upper  portion  of  it 
— in  fact,  attached  to  it.  I  gave  it  as  my  opinion  that,  whatever 
the  mass  was,  it  was  outside  the  uterus,  and  was  adherent  to  it, 
and  that  it  was  not  ovarian.  I  did  not,  however,  express  the 
opinion  at  which  I  arrived  after  the  above  examinations  and 
after  thoroughly  exploring  by  the  rectum,  viz.,  that  it  was  a 
case  of  impacted  and  accumulated  faeces,  which,  having  set  up 
great  irritation,  had  occasioned  inflammation,  effusion  of  lymph, 
and  matting  or  gluing  of  the  bowel  to  the  left  and  upper  por- 
tion or  cornu  of  the  uterus,  that  organ  being  still  enlarged,  its 
involution  after  delivery  being  not  yet  completed,  probably 
owing  to  the  irritation,  inflammation,  and  subsequent  adhesion 
to  which  I  have  referred.  Taking  this  view  of  the  case,  I 
purged  freely  and  continuously  for  some  days,  till  at  length, 
after  the  lapse  of  six  weeks,  I  had  the  satisfaction  of  hearing 
from  my  patient — for  I  did  not  attend  her  continuously  during 
this  period — that  the  tumor  was  all  gone,  and  she  was  quite 
well ;  facts  I  verified  by  careful  manipulation  when  she  last 
visited  me.  The  iodide  of  potassium  had  been  combined  with 
the  aperients,  as  had  also  anodj^nes— the  former  in  hope  of  dis- 
solving adhesions,  the  latter  with  a  view  to  ease  pain.  I  would 
add,   to  show  the  difficulties  which    sometimes  behedge  the 


368  DISEASES    OF   THE    RECTUM    AND    ANTTS. 

diagnosis  in  these  cases,  that  this  patient  had  previously  had 
pronounced  to  her  by  three  medical  men  that  operation  alone 
(gastrotomy)  could  do  her  any  good ;  and  of  this  she  had  a 
mortal  dread,  so  that  all  through  I  buoj^ed  her  up  with,  the 
hope  that  the  knife  might  never  be  required. 

The  swelling  had  commenced  to  be  noticed  about  twelve  or 
fourteen  days  after  the  birth  of  her  child,  was  chiefly  confined 
to  the  left  side,  though  sometimes  it  seemed  to  enlarge,  and  to 
extend  higher  up  and  across  the  middle  line  toward  the  right, 
and  was  so  large  that  it  was  as  though  she  was  at  her  full  time, 
and  when  walking,  even  across  her  room,  she  required  a  towel 
to  support  the  abdomen  ;  at  other  times  it  would  subside,  pre- 
serving, however,  the  same  shape  ;  these  alterations  in  size  were 
synchronous  with  the  action  of  the  bowels,  and  gave  me  a  val- 
uable clue.  The  agony  had  been  very  great,  and  she  told  me 
nothing  had  relieved  her  for  any  length  of  time  till  she  had 
used  the  morphia  suppositories.  At  no  period  was  there  a  dis- 
charge of  matter  indicative  of  any  internal  abscess ;  nor  any 
iiux  of  water  either  into  the  abdominal  cavity  or  into  the  blad- 
der, or  any  way  externally,  which  would  demonstrate  the  exist- 
ence and  rupture  of  an  ovarian  or  other  cystic  growth  ;  there- 
fore, the  only  diagnosis  at  which  I  could  arrive  was  that  the 
bowels  had  become  blocked  during  the  confinement  period,  had 
not  emptied  themselves  fully,  that  an  accumulation  occurred 
and  became  greater  and  greater,  being,  however,  occasionally 
partially  lessened  by  the  aperient  action  of  the  bowels  them- 
selves, which  accounted  for  the  diminution  of  and  subsidence 
that  had  been  noticed  in  the  swelling. 

The  treatment  of  impaction  is  simple,  and  consists  first  of 
all  in  the  entire  removal  of  the  mass.  In  cases  of  paralysis, 
where  the  accumulation  has  not  been  allowed  to  reach  any  very 
great  amount,  and  the  scj^bala  are  small  and  not  very  hard, 
this  may  sometimes  be  accomplished  by  the  use  of  injections 
with  a  long  tube  and  the  assistance  of  the  finger  of  the  opera- 
tor. 

In  women  very  effectual  aid  may  be  rendered  under  simi- 
lar conditions  hy  pressure  from  the  vagina,  by  which  small 
masses  may  be  extruded  one  after  another,  eacli  with  a  certain 
amount  of  pain,  bat  without  laceration  of  the  mucous  mera- 
brane  at  the  anus.  This  plan  of  treatment  will  often  constitute 
one  of  the  regular  duties  of  the  attendant  upon  a  case  of  paral- 


IMPACTED    FAECES    AND    FOREIGN    BODIES.  369 

ysis— a  disagreeable  duty  which  must  be  attended  to  at  certain 
regular  intervals. 

In  cases  of  longer  standing,  however,  these  means  may  be 
entirely  inadequate,  and  all  injections,  no  matter  what  their 
supposed  solvent  virtues,  will  be  of  no  avail  even  if  they  are  not 
at  once  ejected.  In  such  cases  the  operation  of  breaking  up 
and  removing  the  mass  must  be  begun  by  the  administration  of 
ether  and  dilatation  of  the  sphincter.  This  accomplished,  the 
mass  may  be  attacked  with  the  fingers,  an  iron  spoon,  a  pair  of 
lithotomy  forceps,  or  the  scoop  shown  in  Fig.  87,  and  removed 
piece  by  piece.  When  this  has  been  done,  an  injection  may  be 
administered  through  the  long  tube  and  more  matter  will  gen- 
erally come  down  from  the  sigmoid  flexure.  The  impacted 
mass  is  often  as  large  as  the  fist,  and  sometimes  as  a  foetal  head, 
and  the  amount  in  the  sigmoid  flexure  and  colon  may  be  much 
greater  though  not  as  hard,  so  that  at  a  single  sitting  an  enor- 
mous amount  may  be  removed. 


Fig.  87. — Scoop  for  Removing  Impacted  Faeces. 

After  such  an  operation  as  this,  the  patient  must  be  treated 
by  injections  and  a  daily  laxative,  as  will  be  described  in  speak- 
ing of  constipation,  till  the  over-distended  rectum  has  recovered 
its  tone.     This  may  require  a  considerable  time. 

Foreign  Bodies  which  have  been  Swallowed. — Medical  liter- 
ature is  full  of  curious  cases  in  which  foreign  bodies  have  been 
swallowed,  either  accidentally  or  by  design,  and  have  in  some 
cases  passed  the  full  length  of  the  alimentary  canal,  and  been 
safely  voided  with  the  faeces,  or  in  others  have  become  entan- 
gled in  the  mucous  membrane,  and  given  rise  to  much  trouble. 
Every  practitioner  is  familiar  with  cases  of  peach-stones  and 
coins  which  have  been  accidentally  swallowed,  and  knows  how 
generally  such  substances  take  care  of  themselves,  and  cause 
no  symptoms  after  once  passing  the  oesophagus.  Much  larger 
substances,  such  as  whole  or  partial  sets  of  false  teeth,  and  the 
various  things  with  which  performers  in  travelling  shows  enter- 
tain an  audience,  may  also  be  passed  in  safety. 

To  show  what  nature  is  capable  of  in  this  line,  it  may  be 
well  to  enumerate  the  substances  which  were  swallowed  and 
34 


370  DISEASES    OF   THE    RECTUM    AND    ANUS. 

safely  voided  by  a  certain  lunatic  now  become  famous.  The 
patient  stated  that  she  had  been  swallowing  nails,  etc.,  and  a 
dose  of  castor  oil  brought  away  two  pieces  of  faience,  one  or 
two  centimetres  long  and  about  the  same  breadth,  two  nails,  and 
a  pebble.  During  the  following  six  weeks  she  passed  nineteen 
large  pointed  nails,  a  screw  seven  centimetres  long,  numerous 
fragments  of  glass  and  china,  a  piece  of  a  needle,  two  knitting- 
needles,  fragments  of  whalebone,  etc.,  amounting  in  all  to  three 
hundred  grammes.  During  all  this  time  the  patient  ate  and 
drank  as  usual,  and  seemed  in  ordinary  health.1 

Prof.  Agnew  "saw  in  the  dissecting-room  of  the  Philadel- 
phia School  of  Anatomy,  a  female  subject,  afterward  learned  to 
have  been  insane,  in  whose  intestinal  canal  from  jejunum  to 
rectum  were  found  three  spools  of  cotton  partially  unwound, 
two  roller  bandages,  one  of  them  two  and  a  half  inches  wide  and 
one  inch  thick,  the  other  was  partially  unrolled,  one  end  being 
in  the  ileum,  the  other  in  the  rectum ;  a  number  of  skeins  of 
thread,  a  quantity  being  packed  tightly  in  the  csecum  ;  and 
finally  a  pair  of  suspenders." 

Prof.  Gross  records  the  "case  of  a  man  who  swallowed  a 
bar  of  lead,  ten  inches  long,  upward  of  six  lines  in  diameter 
and  one  pound  in  weight,  whilst  performing  some  tricks  of 
legerdemain,"  which  was  removed  by  gastrotomy  and  the 
patient  recovered  in  two  weeks.  He  also  mentioned  another 
case  in  which  a  teaspoon  was  swallowed,  whilst  the  patient  was 
in  a  paroxysm  of  delirium,  which  was  removed  from  the  ilium 
by  enterotomy,  recovery  taking  place  in  a  few  weeks.2 

"  Henrion,  called  Cassandra,  born  in  Metz,  in  1761.  Not  satis- 
fied with  the  various  trades  which  he  followed  in  his  youth,  he 
began  to  force  himself,  at  the  age  of  twenty- two  years,  to  swal- 
low pebbles.  Sometimes  he  swallowed  them  whole  and  with- 
out any  preparation,  and  sometimes  he  broke  them  between  his 
teeth,  after  having  first  heated  them  red-hot  and  then  suddenly 
plunged  them  into  cold  water.  In  this  manner  he  palmed  him- 
self off  as  an  American  savage.  For  several  years  he  had  fixed 
his  residence  nt  Nancy,  and  there  continued  the  same  habits 
which  lie  had  not  interrupted,  swallowing  daily  a  large  number 
of  pebbles,  sometimes  as  many  as  thirty  or  forty.  The  largest 
pebbles  equalled  in  volume  a  large  nut,  but  they  were  usually 

1  Lancet,  1860.  vol.  i.,  p.  2:!. 

'Randolph  Winalow:   Maryland  Medical  Journal,  March,  1880. 


IMPACTED    FJECES    AND    FOREIGN    BODIES.  371 

smaller,  and  Henrion  demonstrated  their  presence  in  the  stom- 
ach by  the  collision  which  he  obtained  by  percussing  the  epi- 
gastric region.  With  the  aid  of  salts  he  passed  them  in  twenty- 
four  hours,  and  often  made  them  do  duty  for  the  next  day. 
He  also  swallowed  live  mice,  though  only  one  in  the  course  of  a 
day,  as  well  as  crabs  of  moderate  size,  after  their  claws  had 
been  cut.  When  the  mice  were  introduced  into  the  mouth,  they 
threw  themselves  into  the  pharynx,  in  which  they  were  soon 
suffocated,  and  their  deglutition  was  then  facilitated  by  that  of 
a  nail.  Upon  the  following  day  it  was  passed  from  the  rectum, 
flayed,  and  covered  with  a  mucous  substance.  At  another 
time  three  large  pennies  were  successively  put  to  the  same  use, 
and  Henrion  found  them  later,  scraped  clean  and  mixed  with 
fsecal  matters. 

"He  continued  this  calling  until  1820.  At  this  time  he 
swallowed  some  nails,  and  then  a  plated  iron  spoon  measuring 
five  and  a  half  inches  in  length  and  one  in  breadth,  for  a  mod- 
erate sum.     He  died  seven  days  later."  ' 

Napoleon  relates  a  case  of  considerable  historic  interest 
where  the  alimentary  canal  was  used  for  the  purpose  of  secret- 
ing despatches. 

' '  When  I  commanded  at  the  siege  of  Mantone,  shortly  be- 
fore the  surrender  of  this  fortress,  a  G-erman  was  arrested  while 
endeavoring  to  enter  the  city.  The  soldiers,  who  suspected  him 
of  being  a  spy,  searched  him  without  success  ;  they  then  threat- 
ened him  in  their  own  language,  which  he  did  not  understand. 
Finally  a  Frenchman  was  called  who  spoke  German  slightly, 
and  who  threatened  him,  in  bad  German,  with  instant  death  if 
he  did  not  at  once  disclose  all  he  knew.  He  accompanied  this 
threat  with  furious  gestures,  drew  his  sword,  placed  the  point 
of  it  upon  his  belly,  and  said  he  was  going  to  slit  him  open. 
The  poor  German,  frightened  and  not  understanding  the  jargon 
of  the  French  soldier,  imagined,  when  he  saw  him  threatening 
his  belly,  that  his  secret  was  disclosed,  and  cried  out  that  it 
was  unnecessary  to  slit  him  open,  and  that  if  he  waited  a  few 
hours  it  could  be  obtained  in  the  natural  manner.  This  gave 
rise  to  fresh  questions  ;  he  stated  that  he  was  the  bearer  of  des- 
patches for  Wurmser,  and  that  he  had  swallowed  them  as  soon 
as  he  found  himself  in  danger  of  being  captured.  He  was  car- 
ried to  my  headquarters,  whither  several  physicians  were  sum- 

1  Arch.  Gen.  de  Med.,  3e  Serie,  1839,  p.  353  (Poulet). 


372  DISEASES    OF   THE    RECTUM    A15TD    ANUS. 

moned.  It  was  proposed  to  administer  a  purgative,  but  they 
stated  that  it  was  best  to  await  the  operation  of  nature.  He 
was  then  confined  to  a  room  under  the  surveillance  of  two  staff 
officers,  one  of  whom  was  constantly  near  him.  After  several 
hours  the  expected  object  was  found.  It  was  inclosed  in  wax, 
and  was  as  large  as  a  nut.  When  opened  it  was  found  to  be  a 
despatch  written  in  the  hand  of  the  Emperor  Francis,  and  which 
requested  him  not  to  be  discouraged  and  to  hold  out  a  few  days 
longer,  when  he  would  aid  him  with  a  strong  column."  Napo- 
leon, upon  these  indications,  left  with  his  troops  and  completely 
defeated  Alvinzi  at  the  Passage  of  the  P6.1 

It  would  be  beyond  the  scope  of  a  work  such  as  this  to  at- 
tempt to  deal  with  the  whole  question  of  foreign  bodies  in  the 
alimentary  canal,  and  the  accidents  which  may  attend  them. 
In  a  general  way,  the  prognosis  is  good  unless  the  foreign  body 
be  a  very  ragged  one  or  a  large  sharp  one  like  a  fork  ;  and  the 
treatment  consists  in  giving  a  diet  like  bread  and  fruit,  which 
will  cause  copious  stools,  with  little  drink,  and  the  avoidance 
of  exercise  such  as  walking.  If  complications  arise,  they  must 
be  treated  on  general  surgical  principles ;  and  at  the  present 
day  no  patient  would  be  allowed  to  die  from  the  effects  of  a 
foreign  substance  in  the  stomach  or  intestines  without  a  sur- 
gical operation  for  its  removal,  provided  only  the  diagnosis 
were  clear. 

The  complications  which  may  attend  the  detention  of  such 
substances  in  the  rectal  pouch  just  above  the  internal  sphincter 
are  ulceration  with  perforation,  hemorrhage,  and  abscess.  Ul- 
ceration may  be  caused  by  the  pressure  of  a  large  body,  and 
may  cover  a  considerable  space,  or  it  may  be  caused  by  the 
pressure  of  the  sharp  ends  of  a  smaller  body,  in  which  case  the 
spots  of  ulceration  will  be  smaller,  and  may  be  located  at  two 
opposite  points  in  the  rectum.  As  a  result  of  ulceration,  there 
will  be  more  or  less  pain,  purulent  discharge,  and  perhaps  also 
a  sharp  haemorrhage  from  the  erosion  of  a  vessel.  When  per- 
foration of  the  wall  of  the  bowel  has  occurred,  inflammatory 
action  is  almost  sure  to  be  excited  in  the  surrounding  parts, 
and  this  may  vary  greatly  in  its  extent  and  gravity.  If  the 
injury  be  above  the  point  of  reflection  of  the  peritoneum,  it  may 
cause  either  a  localized  or  a  general  peritonitis.  A  general  peri- 
tonitis caused  in  this  way  will  be  fatal,  as  it  is  also  generally 

'  Memorial  de  Sainte  Helene,  t.  ii.,  p.  468  (Poxilet). 


IMPACTED    FJECES    AND    FOREIGN    BODIES.  373 

accompanied  by  more  or  less  extravasation  of  faeces.  A  circum- 
scribed peritonitis  with  formation  of  an  abscess  is  a  less  fatal 
complication.  Under  these  circumstances  the  usual  signs  of 
pelvic  abscess  will  be  present — fever,  pain  on  pressure,  tympa- 
nites, painful  defecation,  and  urination — and  by  careful  exami- 
nation a  tumor  may  be  discovered,  either  through  the  rectum 
or  at  the  bottom  of  the  iliac  fossa.  Such  cases,  when  the  tumor 
is  on  the  right  side,  are  often  mistaken  for  cases  of  perityphlitis, 
but  the  tumor  is  not  in  the  same  location.  It  is  deeper  and 
nearer  the  median  line. 

Such  an  inflammation  may  terminate  in  resolution,  provided 
the  cause  be  discovered  and  removed  ;  but  the  usual  termination 
is  in  suppuration,  and  the  pus,  if  not  removed  by  the  surgeon, 
may  find  its  way  into  the  general  peritoneal  cavity  or  into  the 
bladder  or  rectum.  Abscesses  of  the  superior  pelvi-rectal  space 
have  already  been  described,  and  those  which  are  due  to  foreign 
bodies  in  the  bowel  do  not  differ  from  them  in  general  char- 
acters. 

When  the  focus  of  inflammation  is  located  below  the  reflec- 
tion of  the  peritoneum,  the  prognosis  is  less  grave.  Phlegmon- 
ous abscess  may  form  in  the  ischio-rectal  fossa,  and  must  be 
treated  according  to  the  rules  already  laid  down  ;  but  here  the 
difficulty  is  well  within  the  reach-  of  the  surgeon,  and  a  cure 
may  confidently  be  looked  for  by  proper  care. 

Foreign  Bodies  Introduced,  per  Anum. — A  classification  of 
these  cases  is  useless.  The  foreign  bodies  may  be  introduced 
through  traumatism  :  by  the  patient  in  an  honest  endeavor  to 
relieve  himself  of  piles  or  prolapse  ;  by  the  surgeon  for  the  pur- 
pose of  relieving  rectal  disease.  They  are  often  introduced  in  a 
spirit  of  revenge  or  of  trickery  ;  and  most  often  of  all  they  are 
lost  in  the  practice  of  an  unnatural  vice.  Edward  II.  is  said  to 
have  met  his  death  by  having  a  red-hot  iron  thrust  into  the 
rectum.  "We  seized  the  king,"  said  one  of  the  murderers, 
"and  threw  him  forcibly  upon  the  couch,  and,  whilst  I  kept 
him  there  by  the  assistance  of  a  table,  with  a  pillow  on  his  face, 
Gurney  inserted  through  a  horn-tube  a  red-hot  iron  into  his 
bowels."     Gross,  vol.  ii.,  p.  627. 

The  case  of  the  prostitute  into  whose  rectum  the  students  of 
the  University  of  Gottingen  introduced  a  pig's  tail,  butt  end 
first,  is  as  follows  : 

"  Some  students  had  formed  the  plan  of  playing  a  practical 


374  DISEASES    OF    THE    EECTUM    AND    ANUS. 

joke  on  a  prostitute  ;  they  determined  to  push  into  her  anus  a 
frozen  pig's  tail.  They  cut  the  hairs  very  short  in  order  to 
make  them  sharper  and  rougher,  then  dipped  it  in  oil,  and 
forcibly  introduced  it  into  the  woman's  anus,  with  the  excep- 
tion of  a  portion  three  fingers'  breadth  in  length,  which  re- 
mained outside.  Several  attempts  were  made  to  extract  it,  but, 
as  it  could  only  be  withdrawn  against  the  hairs,  the  bristles  en- 
tered against  the  mucous  membrane,  and  gave  rise  to  excruciat- 
ing pain.  In  order  to  relieve  it,  various  oily  remedies  were 
given  by  the  mouth,  and  the  attempt. was  made  to  dilate  the 
anus  with  a  speculum  in  order  to  extract  the  tail  without  vio- 
lence, but  it  was  unsuccessful.  Severe  symptoms  developed, 
violent  vomiting,  obstinate  constipation,  very  high  fever,  and 
intense  pains  in  the  abdomen.  Marchettis  was  summoned  on 
the  sixth  day.  This  physician,  having  been  informed  of  what 
had  happened,  invented  a  very  simple  and  ingenious  device. 
He  took  a  hollow  reed,  one  end  of  which  he  prepared  so  that  he 
could  easily  introduce  it  into  the  anus,  and  completely  inclosed 
the  pig's  tail  in  this  reed,  in  order  to  withdraw  it  without  pain. 
For  this  purpose  he  attached  to  the  tail,  by  the  end  which  pro- 
jected from  the  anus,  a  stout  wax  thread  which  he  passed  into 
the  reed.  With  one  hand  he  pushed  this  form  of  canula  into 
the  rectum,  and  held  the  cord  in  the  other,  to  prevent  the  tail 
being  pushed  in  still  further.  He  succeeded  in  completely  in- 
closing the  tail,  and  promptly  relieved  the  patient."  ' 

A  punishment  for  adultery  among  the  Greeks  is  said  to  have 
been  the  introduction  into  the  rectum  of  a  peeled  radish,  cov- 
ered with  hot  ashes ;  and  cases  in  which  patients  have  fallen 
upon  sharp  and  fragile  objects,  such  as  the  wooden  pickets  of  a 
fence,  which  have  broken  off  and  remained  in  the  rectum,  are 
on  record. 

The  list  of  foreign  bodies  which  have  been  lost  in  the  rectum 
by  ignorant  persons,  in  attempts  to  check  a  diarrhoea  or  to  pre- 
vent the  descent  of  piles  or  prolapse,  is  a  very  long  one,  and  in- 
cludes such  substances  as  bottles,  sticks  of  wood,  and  round 
stones,  some  of  them  of  a  size  relatively  enormous  ;  and  the  use 
of  the  rectal  pouch  by  criminals  for  the  purposes  of  conceal- 
ment is  well  known  to  the  police. 

In  the  Museum  of  Anatomy  and  Pathology  at  Copenhagen 
is  alongish,  oval,  fiat  stone,  about  6f  incheslong,  2| inches  wide, 

1  Hevin,  p.  339. 


IMPACTED    FAECES    AND    FOREIGN    BODIES.  375 

1^  inch  thick,  and  weighing  nearly  two  pounds,  which  a  patient 
in  Bornholm  introduced  into  his  rectum  to  prevent  prolapse, 
from  which  he  had  for  a  long  time  suffered.  The  stone  was  ex- 
tracted by  a  surgeon,  Frantz  Dyhr,  in  1756. ' 

Reali  operated  in  1849,  in  the  hospital  at  Orvieto,  on  a  peas- 
ant who  nine  days  previously  had  introduced  a  piece  of  wood 
into  the  rectum  for  the  purpose,  he  said,  of  economizing  his 
food,  and  preventing  it  from  passing  out  too  quickly.  He  had 
violent  pain.  On  exploration,  the  linger  could  feel  the  base  of 
the  piece  of  wood  lying  in  the  hollow  on  the  sacrum,  and  sur- 
rounded by  the  broken  mucous  membrane.  As  repeated  at- 
tempts at  extraction  led  to  no  result,  Reali  made  an  incision  in 
the  right  iliac  region,  and  found  that  the  foreign  body  lay  in 
the  sigmoid  flexure,  which  it  had  dilated  and  pushed  to  the 
middle  line  nearly  as  far  as  the  umbilicus ;  he  incised  the  in- 
testine, removed  the  foreign  body,  and  closed  the  intestinal 
wound  by  Jobert'  s  method.  The  patient  was  treated  by  pur- 
gatives (!)  and  had  entero-peritonitis  and  abscess  in  the  iliac 
fossa,  but  recovered,  and  two  years  afterward  was  in  perfect 
health.  The  foreign  body  was  a  piece  of  chestnut  wood  of  the 
shape  of  a  truncated  cone,  10  inches  long  and  about  3^  or  4 
inches  in  diameter. 

A  little  case  with  very  ingenious  housebreaking  and  other 
thieves'  instruments  was  found  by  Dr.  Closmadeuc  at  the  ne- 
cropsy of  a  man  in  the  prison  at  Vannes.  The  man  had  died 
of  acute  peritonitis,  from  which  he  had  suffered  seven  days. 
During  his  illness  a  hard,  rather  large  body  was  felt  in  the  left 
side  of  the  hypogastrium  ;  he  said  that  it  was  a  piece  of  wood 
containing  money,  which  he  had  introduced  into  the  rectum  ; 
this,  on  exploration  in  the  meantime,  was  found  empty.  On 
section,  the  case,  which  was  cylindro-conical  in  form,  lay  in  the 
transverse  colon,  with  its  apex  directed  toward  the  caecum  ;  it 
was  of  iron,  and  was  wrapped  in  a  piece  of  lamb' s  mesentery  ; 
it  weighed  about  23  ounces,  was  about  6|  inches  long  and  5i  in 
circumference,  and  contained  thirteen  tools  and  some  coins.2 

"A  monk,  desiring  relief  from  a  severe  colic  from  which  he 
was  suffering,  was  advised  to  introduce  into  the  rectum  a  bottle 
of  Hungary  water,  in  the  cork  of  which  there  was  a  small  open- 

1  Bull,  de  la  Soc.  de  Chir.,  1878,  p.  660. 

2  London  Medical  Record,  December  15,  1878.  Abstract  of  Studsgaard's  paper 
read  before  Soc.  deChir.,  Paris,  October  9,  1878. 


376  DISEASES    OF   THE    RECTUM    AND    ANUS. 

ing,  through  which  the  water  gradually  distilled  into  the  intestine 
(these  bottles  are  usually  long).  He  pushed  it  so  far  that  it  en- 
tered the  rectum  altogether,  whereat  he  was  greatly  astonished. 
He  could  neither  have  an  evacuation  nor  receive  an  enema  ;  in- 
flammation and  death  were  apprehended.  A  midwife  was  con- 
sulted in  order  to  see  whether  she  could  introduce  her  finger 
and  extract  the  bottle,  but  she  was  unable  to  do  it.  Forceps,  a 
ripping-iron,  and  anal  speculse  were  useless.  It  could  not  be 
broken  ;  this  would  have  been  more  disastrous,  as  the  pieces  of 
glass  would  have  wounded  him.  Finally,  a  little  boy,  eight  or 
nine  years  old,  was  found,  who  introduced  his  hand,  and  had 
sufficient  address  to  cure  the  good  monk."  ] 

A  depraved  sexual  appetite  has  been  mentioned  as  account- 
ing for  the  presence  of  many  foreign  bodies.  It  is  known  that 
sexual  orgasm  may  be  excited  by  stimulating  the  reflex  power 
of  the  rectum,  and  it  is  probable  that  at  the  moment  when  the 
orgasm  is  at  its  height,  the  body  used  to  produce  it  is  allowed 
to  escape  from  the  hand  and  is  lost  within  the  bowel.  This  is 
a  habit  which  will  never  be  acknowledged  by  its  victims,  but 
which  may  often  be  assumed  to  exist  by  the  surgeon  in  de- 
praved patients.  The  bodies  used  for  this  purpose  are  generally 
smooth,  long,  and  round,  such  as  glass  bottles  and  pieces  of 
wood.  The  following  case  is  one  in  point,  and  the  age  of  the 
patient  is  suggestive,  for  this  vice  is  said  to  be  more  common  in 
old  men  than  in  others — men  whose  physical  powers  have  not 
kept  pace  with  their  desires. 

"  On  the  afternoon  of  March  1,  1848,  a  young  man  consulted 
Parker  with  regard  to  his  father,  whom  he  had  brought  into  the 
hospital.  After  beating  around  the  bush  and  manifesting  con- 
siderable shame  and  embarrassment,  he  stated  that  his  father, 
named  Loo,  who  was  sixty  years  old,  had  passed  the  previous 
night  in  a  house  of  prostitution.  Overcome  by  drink  and 
opium,  the  old  debauchee  conceived  the  strange  notion  of  push- 
ing a  goblet,  two  and  a  half  inches  in  diameter  and  three  and  a 
half  inches  long,  into  the  vagina  of  his  partner.  During  the 
night,  while  Loo  was  completely  intoxicated,  the  woman  at- 
tempted to  revenge  herself.  She  carefully  introduced  the 
bottom  of  the  goblet  into  the  rectum,  placed  the  end  of  the 
opium  pipe,  which  was  a  foot  and  a  half  long,  into  the  goblet, 
and  pushed  it  into   the  rectum.     The  goblet  disappeared  and 

1  Mem.  de  l'Acad.  de  Chirurgie. 


IMPACTED    FAECES    AND    FOEEIGN    BODIES.  377 

had  been  retained  twenty-four  hours.  A  piece  of  the  edge, 
about  half  an  inch  long,  had  been  broken  off  by  the  friends  in 
attempts  at  extraction.  The  glass  was  firmly  fixed,  and  it  was 
very  difficult  to  pass  the  finger  between  it  and  the  rectum. 
Parker,  determining  to  break  it,  employed  a  cephalotribe  and 
removed  it  in  pieces,  taking  care  to  protect  the  parts  with 
cotton.  The  most  difficult  part  was  the  extraction  of  the  glass, 
which  was  very  irritating.  It  was  done,  but  not  without  diffi- 
culty, by  making  it  see-saw  from  side  to  side.  Considerable 
haemorrhage  occurred,  which  was  arrested  with  sulphate  of 
copper  and  alum.     The  man  recovered  in  two  weeks."1 

It  would  be  interesting  to  enumerate  the  foreign  bodies 
which  have  been  removed  from  this  part  of  the  body,  and  the 
list  would  be  startling  from  the  strangeness  of  the  different 
articles  ;  but  enough  has  been  said  to  indicate  that  almost  any- 
thing, from  a  conical  stone  to  a  club  or  a  coffee  cup,  may  be  en- 
countered by  the  surgeon,  and  to  indicate  the  size  of  the  body 
which  the  sphincter  will  allow  to  pass.  Among  them  may  be 
mentioned  beer  glasses,  mushroom  bottles,  wooden  pepper 
boxes,  wine  bottles  of  all  kinds,  lamp  chimneys,  and  a  part  of 
the  wooden  handle  of  a  baker's  shovel  twenty-two  centimetres 
in  length. 

A  foreign  substance  may  remain  in  the  rectum  for  a  con- 
siderable time  and  finally  be  expelled  spontaneously,  as  in  the 
following  case  reported  by  Weigand.2 

"  A  farmer,  aged  sixty-eight  years,  of  a  robust  constitution, 
but  somewhat  stupid,  introduced  into  the  anus  a  cylindrical 
piece  of  wood  for  the  purpose  of  relieving  his  obstinate  consti- 
pation. However,  he  performed  the  manipulation  so  unskil- 
fully that  the  piece  of  wood  broke  and  remained  partly  within 
the  rectum.  All  attempts  made  to  remove  the  foreign  body 
failed  ;  two  days  later  he  suffered  from  abdominal  and  lumbar 
pains,  dysuria,  and  constipation.  Weigand  being  consulted  by 
the  physician,  recognized  the  symptoms  of  enteritis.  As  the 
introduction  of  a  finger  into  the  rectum  did  not  demonstrate  the 
presence  of  a  foreign  body,  he  restricted  himself  to  combating 
the  inflammatory  symptoms  and  pain  (calomel,  enemata,  nar- 
cotics, leeches).  On  the  eleventh  day  a  purulent,  sanguinolent, 
foetid  fluid  was  evacuated,  after  which  the  patient  felt  remark- 

1  Am.  Journal  of  the  Medical  Sciences,  1849,  p.  409. 

2  Schmidt's  Annalen,  113,  iv.,  p.  95,  1862. 


378  DISEASES    OF    THE    RECTUM    AND    ANUS. 

ably  relieved  ;  but  it  was  impossible  to  discover  any  trace  of 
the  piece  of  wood.  Weigand  then  expressed  serious  doubts  as 
to  whether  a  foreign  body  was  really  contained  in  the  rectum  ; 
but  as  the  patient  resolutely  maintained  that  he  continued  to 
feel  the  piece  of  wood,  renewed  search  was  made,  until  the 
finger  being  introduced  far  in,  encountered  a  rough,  hard  object 
which  it  was  impossible  to  seize  for  want  of  proper  instruments. 
As  circumstances  did  not  indicate  a  necessity  for  more  active 
treatment,  Weigand  contented  himself  with  giving  the  patient 
from  time  to  time  two  or  three  spoonfuls  of  castor-oil,  which 
always  produced  the  discharge  of  a  small  amount  of  muco- 
sanguinolent  faeces.  At  this  time  the  lumbar  and  abdominal 
pains  again  appeared  more  frequently,  and,  on  the  other  hand, 
the  patient's  former  appetite  being  gradually  restored,  he 
walked  about  and  attended  to  light  domestic  duties.  On  the 
thirty-first  day  after  the  accident,  after  having  taken  three 
spoonfuls  of  castor-oil,  he  stated  that  he  had  an  intense  desire 
to  go  to  stool,  when,  in  addition  to  blood  and  pus,  the  piece  of 
wood  made  its  appearance,  0.1357  m.  long,  0.027  thick,  cylin- 
drical, serrated  at  the  broken  end,  and  roughened  on  the  cylin- 
drical surface ;  in  fact  it  was  the  end  of  a  pole  with  which  bean- 
vines  are  propped.  The  patient  recovered  entirely  without 
having  been  subjected  to  any  further  treatment"  (Poulet). 

Prognosis. — The  prognosis  in  cases  of  foreign  bodies  will  de- 
pend greatly  upon  their  size  and  nature.  A  long  body  like  a 
piece  of  wood  may  go  so  far  up  the  bowel  as  to  do  fatal  damage 
before  its  removal ;  and  a  fragile  body  like  glass  may  cause 
fatal  injury  in  the  attempt  to  remove  it.  Again  the  prognosis 
depends  in  great  measure  upon  the  surgical  ability  of  the  one 
in  charge  of  the  case.  A  little  bungling  in  the  treatment  may 
at  any  moment  change  a  case  which  promises  well  into  a  fatal 
one.  Finally,  much  will  depend  upon  the  length  of  time  during 
which  the  body  has  remained  in  the  rectum  ;  and  it  is  not  very 
uncommon  for  patients  who  have  met  with  an  accident  in  the 
practice  of  this  secret  vice  to  conceal  the  real  nature  of  the 
trouble  which  they  well  understand  till  they  are  forced  by 
suffering  to  confess.  In  this  way  a  week' s  valuable  time  may  be 
lost  and  a  fatal  amount  of  injury  be  done. 

Treatment. — Each  case  of  foreign  body  must  be  treated  by 
itself,  and  besides  a  few  general  principles  which  apply  equally 
to  all  cases,  the  surgeon  will  be  left  entirely  to  his  own  ingen- 


IMPACTED    FAECES    AND    FOEEIGN    BODIES.  379 

uity.  The  one  guiding  principle  should  be  to  avoid  doing  fresh 
injury  in  the  attempt  at  removal.  Only  the  smaller  and  least 
friable  of  bodies  can  be  removed  without  a  previous  dilatation 
of  the  sphincter  under  ether,  and  in  most  cases  it  will  be  advis- 
able to  incise  the  anus  in  the  median  line  down  to  the  tip  of 
the  coccyx  as  a  preparatory  measure  to  all  treatment.  This 
step  will  sometimes  render  a  body  movable  which  before  was 
absolutely  immovable,  and  thus  open  the  way  for  its  extrac- 
tion. 

Having  opened  the  way  to  the  body,  it  may  sometimes  be 
removed  by  passing  the  whole  hand  into  the  rectum  and  seizing 
it.  At  other  times  forceps  may  be  used  with  advantage,  and 
these  may  be  of  any  shape  which  seems  best  to  answer  the 
purpose  intended,  including  the  obstetric  forceps,  which  have 
been  found  useful  in  many  cases.  If  a  bottle  has  been  intro- 
duced with  the  mouth  downward  a  string  may  be  secured 
around  the  neck  for  the  purpose  of  traction,  but,  unfortunately, 
in  almost  all  cases  the  position  will  be  reversed.  In  cases  of 
long  bodies  the  lower  end  is  not  infrequently  firmly  wedged 
in  the  hollow  of  the  sacrum — so  firmly  as  to  resist  all  efforts 
at  dislodgment.  Under  such  circumstances  fatal  injury  may 
easily  be  done  by  the  operator  by  persistence  in  the  attempt. 

Above  all  things  the  surgeon  must  avoid  breaking  such  a 
substance  as  a  cup,  for  experience  has  proved  that  after  this 
has  happened,  removal  without  causing  great  injury  is  almost 
impossible. 

Certain  complications  may  at  any  time  arise  in  the  treatment 
of  these  cases,  one  of  which  is  recorded  by  Desault.1  A  man, 
aged  forty-seven  years,  entered  the  Hotel  Dieu  on  April  17, 
1762,  in  order  to  have  a  crockery  vessel  extracted  from  his  rec- 
tum, which  he  had  introduced  a  week  previously  in  order  to 
overcome,  as  he  said,  his  obstinate  constipation.  This  vessel 
was  a  preserve  jar,  the  handle  of  which  was  broken  and  the 
bottom  detached.  It  was  conical  in  shape  and  three  inches 
long  ;  it  had  been  introduced  by  the  smaller  end,  which  was 
two  inches  in  diameter. 

When  the  patient  presented  himself  at  the  hospital,  he  had 
already  made  efforts  to  extract  the  foreign  body,  but  an  escape 
of  blood  and  the  excessive  pains  had  compelled  him  to  suspend 
his  efforts.     The  upper  part  of  the  rectum  was  infolded  and  in- 

1  Journal  de  Chir.,  t.  iii.,  p.  177  (Poulet). 


380  DISEASES    OE    THE    EECTUM    AND    ANUS. 

vaginated  in  the  vessel,  and  formed  a  very  hard  tnmor,  which 
filled  it  completely.  The  surrounding  parts  were  inflamed,  and 
this  fact  rendered  the  extraction  more  difficult.  Desault  made 
the  patient  lie  upon  the  side,  and  then,  separating  the  intestine 
from  the  walls  of  the  vessel,  he  succeeded  in  seizing  the  latter 
with  a  strong  extractor,  which  he  pushed  up  as  far  as  possible 
and  which  was  held  by  an  assistant.  By  means  of  this  point  of 
support,  and  with  another  extractor  introduced  in  the  same 
manner,  he  succeeded  in  breaking  the  vessel  and  in  extracting 
it  in  small  pieces  without  wounding  the  rectum.  The  operation 
was  neither  long  nor  painful,  though  it  was  necessary  to  intro- 
duce the  extractors  a  large  number  of  times.  After  all  the 
pieces  had  been  removed,  Desault  pushed  back  the  inverted 
portion  of  the  rectum  by  means  of  a  charpie  tampon  six  inches 
long  and  two  and  a  half  in  diameter,  which  he  pushed  in 
altogether  after  having  covered  it  with  cerate.  Below  this  were 
placed  a  large  amount  of  charpie,  several  compresses,  and  a 
triangular  bandage  which  supported  the  whole  dressing.  The 
dressing  was  renewed  twice  a  day  on  account  of  the  relaxation, 
which  did  not  cease  till  the  sixth  day.  Then  the  intestine  no 
longer  protruded  when  the  patient  went  to  stool,  and  such  large 
tampons  were  not  required.  They  were  discontinued  entirely 
after  the  tenth  day,  when  the  ruptures  had  cicatrized,  and  the 
man  left  the  hospital  entirely  cured  two  weeks  after  the  operation. 
In  cases  where  a  long  body  has  become  firmly  wedged  into 
the  lower  end  in  the  hollow  of  the  sacrum,  the  proper  treatment 
consists  in  opening  the  abdomen,  and  this  should  be  done  after 
an  attempt  to  remove  it  per  anum  has  been  continued  a  reason- 
able time,  and  before  injury  has  been  done  in  such  an  attempt. 
It  is  not  necessary  to  describe  the  operation  of  laparo-entero- 
tomy  in  this  connection.  The  incision  may  be  made  either  in 
the  median  line  or  in  the  groin.  In  the  "Surgical  History  of 
the  War  of  the  Rebellion,"  Vol.  II.,  p.  322,  there  is  a  history  of 
one  such  operation  performed  upon  a  sailor  who  had  introduced 
a  stone  five  and  a  quarter  inches  long  by  three  wide.  The 
colon  had  been  perforated  and  the  stone  was  removed  from  the 
peritoneal  cavity  by  an  incision  near  the  umbilicus.  The  man 
recovered.     The  oldest  known  case1  was  reported  by  Realli  in 

1  For  this  and  maDy  other  interesting  facts  in  connection  with  this  subject  the 
reader  is  referred  to  Poulet's  work  on  Foreign  Bodies  in  Surgery.  Wood's  Library  of 
Standard  Medical  Authors,  1880. 


IMPACTED    F.ECES    AND    FOEEIGTT    BODIES.  381 

the  Bull,  de  Soc.  Medich.,  and  Gaz.  Med.,  July,  1851,  and  being 
the  one  which  has  served  as  a  guide  for  all  subsequent  ones,  we 
give  it  in  full : 

Case.  Foreign  Body. — "On  December  18,  1848,  a  peasant 
was  brought  in  the  hospital  of  Orvieto  in  a  condition  of  extreme 
weakness.  Mne  days  previously,  having  hit  upon  the  ingen- 
ious idea  that,  if  he  prevented  the  discharge  of  food  he  could 
limit  the  quantity  to  be  swallowed,  he  introduced  a  piece  of 
wood  into  the  rectum  ;  all  his  attempts  at  removal  only  served 
to  push  it  in  still  further.  The  ringer  could  only  touch  the  end 
of  the  object,  and  it  was  firmly  fixed  in  such  a  manner  as  not  to 
yield  to  any  tractions  which  could  be  made  upon  it  with  such  a 
slight  purchase. 

"After  the  failure  of  all  attempts  at  removal,  the  foreign 
body  completely  obliterating  the  intestinal  cavity,  and  the  pa- 
tient being  threatened  with  death  from  his  atrocious  sufferings, 
Realli  decided  to  operate.  After  having  cut  the  abdominal 
walls  on  the  left  side,  he  could  distinctly  feel  the  stake  in  the 
descending  colon.  He  desired  to  push  it  down  to  the  anus,  but 
the  attempts  proved  unsuccessful,  and  he  was  compelled  to  in- 
cise the  intestine.  Only  after  this  was  done  could  he  remove 
the  body,  which  was  ten  centimetres  long  and  more  than  three 
centimetres  in  diameter  at  the  base.  The  point  was  rounded 
and  very  soft.  Ko  fseces  were  retained  above  the  plug,  but  the 
mucous  membrane  was  blackish,  the  peritoneal  coat  strongly 
injected,  and  the  thickness  of  the  intestinal  wall  markedly  in- 
creased. 

"  The  wound  in  the  intestine  was  united  by  a  suture,  which 
was  applied  according  to  Jobert's  plan.  The  lips  of  the  wound 
in  the  abdomen  were  united  by  means  of  an  interrupted  suture. 
Cold,  and  then  iced  applications  were  made  over  the  operated 
region.  Two  doses  of  castor-oil  were  administered.  There  was 
a  purulent  discharge  from  the  anus.  During  the  first  few  days, 
the  tumefaction  of  the  walls  of  the  intestines  prevented  the  ad- 
vance of  freces,  and  caused  meteorism  and  vomiting.  Three 
bleedings,  two  applications  of  leeches,  and  a  few  doses  of  castor- 
oil  put  an  end  to  these  symptoms,  which  had  acquired  an  alarm- 
ing character.  The  evacuations  from  the  bowels  were  again 
passed  on  the  fifth  day.  Toward  the  fourteenth  day,  the 
wounds  had  cicatrized.  Two  years  later,  the  health  remained 
perfect." 


382  DISEASES    OP    THE    RECTUM    AND    ANUS. 

In  a  paper  read  before  the  Soc.  de  Cliirurgie,1  Studsgaard,  of 
Copenhagen,  reports  the  following  similar  case  : 

Case.  Foreign  Body. — "J.  F.,  footman,  aged  thirty-five 
years,  was  admitted  on  January  10,  1878,  to  the  Copenhagen 
Hospital,  and  left  cured  on  April  16,  1878.  The  night  before 
entering  he  had  introduced  an  empty  mushroom  bottle  into 
the  rectum,  the  neck  of  the  bottle  being  uppermost,  in  order,  as 
he  stated,  to  relieve  a  rebellious  diarrhoea,  and  on  the  morning 
of  January  10th  he  was  obliged  to  call  a  physician,  acute  pains 
being  experienced  in  the  abdomen. 

"He  was  anaesthetized  with  chloroform,  but  the  bottle, 
which,  previous  to  the  narcosis,  had  been  felt  in  the  rectum, 
slipped  further  up.  He  was  exhausted  by  the  passage  and  the 
increasing  pains  ;  vomiting  of  mucus.  The  bottle  could  be  felt 
through  the  somewhat  tense  abdominal  wall  along  the  median 
line  on  the  left  side,  the  bottom  being  near  the  horizontal  ramus 
of  the  pubis.  In  the  evening,  profound  narcosis  and  posterior 
linear  rectotomy  ;  the  hand  was  introduced  as  far  as  the  third 
sphincter,  which  was  not  forced,  on  account  of  its  resistance. 
The  bottle  was  then  pressed  from  the  outside  down  into  the 
pelvis,  but  it  descended  in  a  loop  of  the  intestine  in  front  of  the 
rectum.  Immediately  afterward,  antiseptic  laparo-enterotomy, 
through  the  median  line,  by  an  incision  ten  centimetres  long, 
commencing  at  the  umbilicus.  A  loop,  which  was  thought  to 
be  the  sigmoid  flexure,  was  extracted,  and  the  bottle  was  then 
slowly  removed  through  an  incision  four  centimetres  long, 
which  was  made  upon  the  orifice  and  upper  part  of  the  neck. 
The  entire  circumference  was  protected  by  sponges  and  com- 
presses between  the  faeces,  and  the  intestinal  incision  was  closed 
by  twelve  to  fourteen  catgut  sutures,  according  to  Lambert's 
method,  the  peritoneal  surfaces  having  been  freely  washed.  In 
order  to  be  on  the  safe  side,  the  sutures  were  tied  with  three 
knots  ;  the  intestines  were  then  introduced,  and  the  abdominal 
wound  united  with  eight  silk  sutures,  tied  alternately  with 
knots  and  the  figure  of  eight.     The  operation  lasted  an  hour. 

"  The  bottle  was  seventeen  centimetres  long,  the  diameter  of 
the  bottom  was  five  centimetres,  that  of  the  neck  three  centi- 
metres ;  the  opening  contained  a  notch,  which  was  evidently  of 
old  date,  about  half  a  centimetre  long,  and  presenting  cutting 
edges.     The  recovery  occupied  a  long  time,  and  the  prognosis 

1  Bull,  de  la  Soc.  de  Chir.,1878,  p.  662. 


IMPACTED    FAECES    AND    FOREIGN    BODIES.  383 

was  uncertain  for  a  very  protracted  period,  on  account  of  a 
local  peritonitis  with  abscess  formation,  which  I  incised  both 
upon  the  median  line  and  through  the  rectum,  upon  the  pos- 
terior wall  of  which  it  projected.  Gas  began  to  pass  two  days 
after  the  operation  ;  from  the  ninth  day  on,  he  had  spontaneous 
evacuations,  which  were  well  formed,  and  contained  no  traces 
of  pus." 

One  other  case  of  this  kind  has  been  placed  on  record  l  by 
Verneuil. 

Case. — A  man,  aged  forty-five,  had  been  in  the  habit  of 
stopping  up  his  rectum  to  overcome  an  incontinence  of  faeces 
which  had  resulted  from  two  previous  attacks  of  dysentery. 
For  this  purpose  he  used  various  large  bodies,  taking  the  pre- 
caution to  tie  to  them  a  piece  of  cord,  the  ends  of  which  were 
left  hanging  outside.  But  one  day  he  had  no  cord,  and  a  cyl- 
indrical piece  of  wood,  ten  centimetres  long  and  about  eight  in 
diameter,  escaped  into  the  upper  part  of  the  rectum,  and  could 
neither  be  forced  down  nor  reached  with  the  finger.  All  the 
efforts  which  were  immediately  made  by  a  physician  of  the 
place  only  forced  the  body  further  from  the  anus. 

In  this  condition  the  patient  entered  the  service  of  M.  Ver- 
neuil. There  were  few  signs  of  retention,  but  the  finger  could 
not  be  made  to  reach  the  foreign  body  ;  only  with  the  hand  on 
the  abdomen  could  it  be  felt  in  the  left  iliac  fossa.  It  was  so 
high  that  linear  proctotomy  could  give  no  assistance,  and  there- 
fore laparotomy  was  decided  upon.  The  plan  of  operation  was 
the  following :  Through  a  small  abdominal  incision  to  search 
for  the  sigmoid  flexure,  in  which  the  body  was  probably  lodged  ; 
to  draw  the  sigmoid  flexure  outward,  and,  if  healthy,  to  incise 
it,  remove  the  body,  sew  up  the  gut  and  replace  it  in  the  abdo- 
men. If,  on  the  contrary,  it  was  diseased,  to  stitch  it  to  the 
abdominal  wall,  and  make  an  artificial  anus.  But  the  foreign 
body  was  so  fixed  in  the  upper  part  of  the  rectum,  with  its  long 
axis  from  behind  forward,  as  to  be  immovable,  and  by  reason 
of  this  immobility  of  the  rectum,  the  former  plan  of  operation 
had  to  be  abandoned. 

Fortunately,  it  was  possible  to  dislodge  the  body  from  this 
fixed  position,  and  M.  Lucas  Championniere,  who  at  that  mo- 
ment practised  the  rectal  touch,  received  it  upon  the  end  of  his 
finger.     While  an  assistant  fixed  the  body  by  pressing  on  the 

1  Prog.  Med.,  May  15,  1880. 


384  DISEASES    OF    THE    RECTUM    AND    ANUS. 

abdomen,  M.  Verneuil  endeavored  to  seize  it  with  the  forceps  of 
Muzeux,  or  to  tix  it  with  a  gimlet,  but  without  success.  Linear 
proctotomy  was  then  resorted  to,  and  M.  Yerneuil  succeeded  in 
moving  the  body  with  one  of  the  blades  of  a  lithotomy  forceps, 
bringing  it  down,  and  seizing  it  with  another  pair  of  strong  for- 
ceps. The  instrument  slipped  many  times  on  the  bark  of  the 
wild  cherry  wood,  and  it  was  only  after  many  long  and  painful 
attempts,  practised  with  a  very  defective  stock  of  tools,  that 
the  foreign  body  was  finally  withdrawn.  It  was  followed  by  a 
discharge  of  very  foetid  faecal  matter  and  a  little  blood.  The 
result  of  the  operation,  thanks  to  the  precaution  taken  during 
the  manoeuvres  and  the  treatment  subsequently  employed,  sur- 
passed all  expectations.  The  abdominal  wound  healed  by  first 
intention  under  Lister's  dressing,  and  a  soft-rubber  catheter, 
kept  permanently  in  the  rectum,  through  which  chloral  was  in- 
jected every  two  hours,  prevented  any  complications  in  that 
part. 

These  four  cases  indicate  with  sufficient  clearness  the  general 
rules  which  should  guide  the  practitioner.  The  operation  is 
applicable  only  to  bodies  high  up  in  the  rectum.  The  point  of 
incision  may  be  in  the  median  line,  over  the  sigmoid  flexure  in 
the  left  loin,  or  over  what  seems  to  be  the  most  prominent  point 
of  the  foreign  body,  wherever  that  may  be.  If  the  intestine  is 
healthy,  it  may  be  closed  and  returned  into  the  body.  If  not, 
an  artificial  anus  should  be  made  at  the  point  of  incision. 

It  is  worthy  of  note  that  all  of  the  cases  thus  far  recorded 
have  ended  in  recovery. 

Note. — The  following  cases  have  come  to  my  notice  within  the  past  year: 

Russell,  G. — Case  of  intestinal  obstruction  caused  by  a  wine-bottle;  removal  by 
abdominal  section  ;  death.     British  Medical  Journal,  May  28,  1881. 

Gentiliiomme. — Corps  etranger  du  rectum  deplace  et  arrete  dans  l'S  iliaque  ;  ex- 
traction par  l'abdomen,  suture  de  l'intestin;  guerison.     Union  Med.,  Septembre,  1881. 

BrLLROTii. — Foreign  body  in  the  sigmoid  flexure.  Laparotomy.  Enterorraphy. 
Death.  Wiener  Med.  Woch.,  Nos.  3,  5,  7,  1881.  In  this  case  the  foreign  body  (a 
pencil,  7  ctm.  long)  had  been  in  the  body  three  weeks,  and  the  patient  was  in  collapse 
from  perforation  at  the  time  of  the  operation. 


CHAPTER   XIV. 

PRURITUS   ANI. 

Pruritus  generally  a  Symptom  of  some  other  Disease. — Description. — Causes. — Rela- 
tion of  Internal  Haemorrhoids,  Fistula,  Worms,  Parasites,  and  Eczema  to  Pruri- 
tus.— Treatment  of  Eczema. — Herpes  and  Erythema. — Constitutional  Conditions 
causing  Pruritus. — Dependence  upon  Constipation. — Treatment  of  Constipation. 
— General  Treatment  of  Pruritus. 

Pruritus  ani — itching  at  the  anus — is  generally  a  symptom  of 
some  other  disease  such  as  haemorrhoids  or  eczema,  but  it  is 
often  present  in  a  marked  degree  when  no  cause  for  its  exist- 
ence can  be  discovered.  It  is  an  exceedingly  painful  and  an- 
noying affection,  and  one  which  will  often  tax  the  powers  of  the 
surgeon  to  the  utmost  for  its  cure.  It  is  met  with  in  both  men 
and  women,  and  seems  to  be  dependent  upon  no  particular  gen- 
eral state,  being  found  in  rich  and  poor,  the  overfed  and  under- 
fed, the  professional  man  of  nervous  constitution  and  the  la- 
borer, alike. 

The  disease  is  marked  by  an  itching  at  the  anus  which  is 
more  or  less  constant,  but  is  generally  worse  after  the  sufferer 
has  become  warm  in  bed  at  night.  The  itching  causes  an  at- 
tempt at  relief  by  scratching,  and  the  scratching,  though  it  may 
be  controlled  during  the  day,  is  generally  practised  uncon- 
sciously during  sleep  to  an  extent  which  causes  laceration  of 
the  skin.  The  itching  in  bad  cases,  even  when  constant,  is 
marked  by  exacerbations  and  remissions,  and  may  cause  an 
amount  of  suffering  which  is  simply  unbearable. 

The  disease  is  attended  by  certain  changes  in  the  appear- 
ance of  the  parts.  The  skin  becomes  thickened  and  parchment- 
like  (Fig-  88),  or  else  eczematous  and  moist  from  exudation.  It 
may  be  red  from  the  scratching,  or  there  may  be  quite  a  char- 
acteristic loss  of  the  natural  pigment  of  the  anus.  In  the  latter 
case  the  skin  becomes  of  a  dull-whitish  color,  and  this  will 
oftener  be  noticed  where  the  disease  is  of  long  standing  and 
severe.  The  exudation  may  be  very  marked  where  the  itching 
25 


.°»86  DISEASES    OF    THE    RECTUM    AND    ANUS. 

is  slight,  and  maybe  attributed  by  the  patient  to  trouble  within 
the  rectum  instead  of  to  its  real  source.  Associated  with  the 
changes  in  the  skin  it  is  not  at  all  uncommon  to  find  one  or 
several  fissures. 

Causes. — The  cause  of  pruritus  may  sometimes  be  easily 
discoverable,  and  in  such  cases  a  cure  rapidly  follows  its  re- 
moval. For  example,  pruritus  is  often  a  symptom  of  internal 
haemorrhoids,  and  is  easily  and  effectually  cured  by  their  re- 
moval. Again  it  is  often  a  symptom  or  complication  of  a  fis- 
tula with  a  small  external  opening,  such  as  may  easily  be  over- 
looked in  a  cursory  examination  ;  and  is  cured  by  the  ordinary 


^P^^fe 


Fig.  88. — Thickened  Condition  of  the  Skin  in  Pruritus.    (Esmarch.) 

operation  and  the  consequent  cessation  of  the  discharge  upon 
which  it  depends.  It  is  often  dependent  upon  the  presence  of 
the  oxyuris  vermicularis  in  the  rectum,  and  in  every  case  these 
should  be  carefully  looked  for.  If  they  are  present  they  may 
generally  be  seen  like  small  pieces  of  white  thread  between  the 
radiating  folds  at  the  margin  of  the  anus,  especially  at  night 
when  the  itching  begins.  They  may  generally  be  eradicated  by 
certain  simple  measures,  the  best  known  of  which  is  an  enema 
of  lime-water,  or  of  carbolic  acid,  3  j. ;  glycerin,  |  j. ;  and  water, 
3  vij.,  injected  after  each  passage.  Turpentine  and  tincture 
of  iron  may  be  used  for  the  same  purpose,  and  are  both  very 
effectual ;  but  the  parasites  are  much  more  easily  removed  in 
children  than  in  adults,  and  I  have  had  one  case  which  was  ex- 


PRURITUS    ANI.  387 

ceedingly  intractable,  and  in  which  I  have  never  been  able 
to  keep  the  worms  from  returning  for  any  great  length  of 
time.  A  single  examination  should  never  be  considered  as 
proof  of  the  absence  of  this  parasite  in  an  obstinate  case  of 
pruritus. 

Instead  of  a  parasite  located  within  the  rectum,  pruritus  is 
occasionally  easily  accounted  for  by  the  presence  of  pediculi. 
In  such  a  case  the  diagnosis  and  cure  are  alike  easy. 

Again  the  parasite  may  be  vegetable  instead  of  animal,  and 
the  itching  may  be  due  to  the  disease  known  as  eczema  mar- 
ginatum. In  this  case  the  diagnosis  will  rest  upon  the  finding 
of  the  spores  under  the  microscope  in  the  epidermis  scraped 
from  the  edge  of  the  affected  spot  and  moistened  with  glycerine. 
The  most  effectual  remedy  for  this  condition  is  a  wash  of  equal 
parts  of  sulphurous  acid  and  water  frequently  applied  with  a 
soft  cloth,  and  gradually  increased  in  strength,  if  necessary,  up 
to  the  pure  acid,  which  latter  is,  however,  generally  a  painful 
application,  and  one  which  will  readily  blister.  The  acid,  even 
when  diluted  to  a  considerable  extent,  will  blister  if  covered 
with  a  cloth.  Strong  tincture  of  iodine  applied  with  a  brush  is 
also  an  effectual  remedy  in  eradicating  the  plant. 

Pruritus  may  also  be  dependent  upon  other  skin  diseases, 
among  which  chronic  eczema  is  perhaps  the  most  common,  and 
this  is  to  be  treated  exactly  here  as  elsewhere  in  the  body,  first 
by  general  measures  directed  to  the  constitutional  state,  and 
second,  by  local  applications.  The  congestion  and  the  thicken- 
ing of  the  skin  must  first  be  remedied,  and  for  this  purpose  very 
hot  water,  compound  tincture  of  green  soap,  and  if  necessary  a 
solution  of  caustic  potash,  may  be  applied.  The  water,  to  be  of 
any  use,  must  be  as  hot  as  the  fingers  can  bear,  and  should  be 
applied  to  the  part  with  a  soft  cloth  and  held  there  till  it  begins 
to  cool.  This  may  be  repeated  half  a  dozen  times,  but  all 
rubbing  should  be  carefully  avoided  both  during  the  applica- 
tion and  in  drying  the  parts  after  it.  This  is  a  favorite  remedy 
with  most  dermatologists  ;  it  should  be  used  just  before  going 
to  bed,  and  is  often  in  itself  sufficient  to  insure  a  good  night's 
sleep. 

If  there  be  thickening  of  the  skin  from  effusion,  a  stronger 
application  than  hot  water  will  be  necessary ;  and  for  this  the 
compound  tincture  of  green  soap  is  a  good  remedy  ;  or  the  so- 
lution of  potash  (gr.  v.-  §  i.)  or  liquor  potassse  may  be  resorted 


3S8  DISEASES    OF    THE    RECTUM    AND    ANUS. 

to  with  caution.     The  formula  for  the  compound  tincture  of 
green  soap  is  the  following  : 

IJ .   Saponis  viridis, 

Olei  cadini, 

Alcohol aa .  3*  j. 

M. 

It  is  a  much  stronger  preparation  than  the  simple  green  soap, 
and  also  a  much  more  disagreeable  one,  but  it  is  very  effectual 
and  should  be  well  rubbed  into  the  part  once  a  day.  These 
remedies  should  be  followed  at  once  by  soothing  ointments,  or 
lotions.  A  good  ointment  is  the  ordinary  oxide  of  zinc  made 
soft  and  applied  gently,  and  one  which  is  pretty  certain  to' 
allay  itching  is  that  made  of  chloroform  ( 3  j.-  3  j.).  This  soon 
loses  its  power  by  the  evaporation  of  the  chloroform,  and  should 
on  this  account  be  kept  in  a  wide-mouthed  glass  bottle,  tightly 
corked,  and  should  be  frequently  renewed.  Another  favorite 
application,  and  one  which  is  very  generally  effectual,  consists 
in  a  lotion  of  carbolic  acid.     The  formula  is  : 

IJ .  Acid,  carbolic! §  ss. 

Glycerinse 3  j. 

Aquas 3  iij. 

M. 

This  may  be  applied  at  night,  and  if  found  to  be  too  strong 
may  be  diluted  by  the  patient.  In  a  more  dilute  form  it  may 
also  be  continued  for  a  considerable  time  after  all  symptoms 
have  ceased. 

For  the  sake  of  those  who  have  never  encountered  an  obsti- 
nate case  of  this  disease,  but  who  are  pretty  sure  at  some  time 
to  have  both  knowledge  and  ingenuity  taxed  to  the  utmost,  I 
will  give  one  or  two  more  formulas  which  have  been  found  re- 
liable. The  following  comes  from  Allingham,  and  by  it  alone 
he  has  "seen  a  bad  case  cured  in  forty-eight  hours :  " 

I£.  Liquoris  carbonis  detergens  (Wright's), 

Glycerime aa.  §  j. 

Pulv.  zinci  oxidi, 

( lalamin.  prep aa.  §  ss. 

Pulv.  sulph.  precip 3  ss. 

Aqiue  purse ad .  3  vi. 

M. 


PRURITUS   ANI.  389 

The  part  affected  is  to  be  thickly  painted  over  with  this  once 
or  twice  a  day  and  allowed  to  dry.  The  white  precipitate  oint- 
ment made  soft  with  vaseline  or  glycerine  is  also  a  good  appli- 
cation, and  the  following  lotion,  also  from  Allingham,  will  often 
work  well  in  allaying  irritation  : 

IJ .  Sodse  biboratis 3  ij. 

Morph.  hydrochlor gr.  xvi. 

Acidi  hydrocyanic,  dil 1 ss. 

Glycerinse 3  ij- 

Aquae ad.  fviij. 

M. 

This  should  be  applied  to  the  part  four  or  five  times  in  the 
twenty-four  hours.  Dr.  Bulkley1  has  also  recommended  the 
following  as  being  useful,  and  I  have  often  found  it  so  : 

# .  Ungt.  picis 3  iij. 

"      bellad 3  ij. 

Tr.  aconit.  rad 3  ss. 

Zinci  oxidi 3  j- 

Ungt.  aquae  ros 3  iij. 

M. 

The  following  prescription  has  also  been  very  efficient  in  my 
hands.     I  am  indebted  for  it  to  Dr.  Salisbury  : 

$ .  Menthol 3  j. 

Simple  cerate %  ij. 

Oil  sweet  almonds %  j. 

Carbolic  acid > 3  j- 

Pulv.  zinci  ox 3  ij. 

M.  Apply  morning,  noon,  and  night,  after  cleansing  the 
parts. 

An  ointment  of  chloral  and  camphor,  a  drachm  of  each  to 
the  ounce,  is  also  at  times  effectual  in  allaying  itching. 

There  are  two  other  skin  diseases  either  of  which  maybe  the 
cause  of  pruritus — herpes  and  erythema.  Herpes  at  the  margin 
of  the  anus  is  the  same  as  when  seen  on  the  lips.  In  the  latter 
case  it  heals  spontaneously,  in  the  former  a  dressing  may  be 
necessary.  This  may  consist  simply  of  a  dry  powder  such  as 
zinc  or  bismuth,  or  of  one  of  the  lotions  already  mentioned. 

1  The  Medical  Record,  December  18,  1880. 


390  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Erythema  will  be  found  chiefly  in  fat  people,  where  it  is  due  to 
contact  of  the  opposing  cutaneous  surfaces.  It  also  is  best 
treated  by  the  application  of  diy  powders,  and  by  separating 
the  opposed  surfaces  by  a  la}7er  of  dry  sheet  lint  or  old  muslin. 

These  are  the  most  palpable,  and  perhaps  also  the  most  com- 
mon causes  of  pruritus,  but  there  are  many  cases  in  which  the 
cause  is  not  so  easily  discoverable,  because  it  is  -a  constitutional 
and  not  a  local  one.  Where  no  local  cause  can  be  detected,  a 
careful  inquiry  must  be  instituted  with  regard  to  the  patient's 
general  health  and  habits.  If  chronic  constipation  be  present, 
this  must  first  of  all  be  overcome,  for  this  is  in  itself  an  efficient 
cause  for  the  disease.  The  treatment  of  chronic  constipation  is 
by  no  means  a  simple  matter.  It  may  be  begun  with  a  purga- 
tive such  as  three  compound  cathartic  pills,  for  the  sake  of 
opening  the  way  for  future  treatment,  but  here  the  administra- 
tion of  purgatives  should  end,  for  their  repeated  administration 
is  calculated  to  do  harm  rather  than  good,  by  substituting 
an  occasional  over-action  for  the  daily  one  which  indicates  a 
healthy  state  of  the  intestinal  tract.  The  following  suggestions 
may  be  found  of  use  in  the  treatment  of  this  condition,  which 
is  one  that  must  be  overcome  at  the  commencement  of  the 
treatment  of  any  rectal  affections  with  which  it  may  be  asso- 
ciated. 

Constipation  may  be  due  to  deficient  action  of  either  the 
small  or  the  large  intestine,  and  this  deficient  action  in  either 
case  may  be  the  result  either  of  deficient  secretion  or  deficient 
nerve  power. 

.  Deficient  secretion  is  very  apt  to  be  associated  with  hepatic 
disturbance,  and  is  marked  by  dull  headache,  bad  taste  in  the 
mouth,  viscid  secretion  from  the  buccal  glands,  etc.  This  is  a 
condition  pretty  sure  to  be  aggravated  by  cathartics,  for  the 
■  n  that  the  temporary  increase  in  secretion  which  they 
cause  is  followed  by  a  corresponding  decrease,  which  serves 
only  to  make  the  patient  worse  than  before.  For  the  purpose 
of  increasing  the  natural  secretion  of  the  small  intestine,  the 
fruits  containing  citric  acid,  such  as  oranges,  and  other  fruits, 
such  as  figs  and  apples,  when  the  patient  can  digest  them,  all 
serve  a  good  purpose.  Water  is  also  an  excellent  remedy,  and 
two  tumblerfuls  of  it  taken  in  the  morning  will  often  be  very 
beneficial.  To  it  may  be  added  a  slight  saline,  which  decreases 
its  capability  for  absorption  ( 3  ss.-O.i.),  and,  therefore,  increases 


PRURITUS    ANI.  391 

the  peristalsis  ;  and  the  addition  of  a  single  grain  of  quinine  is 
said  to  greatly  increase  the  effect.1  This  treatment,  if  patiently 
persisted  in  for  a  few  weeks,  will  generally  be  followed  by  a 
good  result. 

Deficient  innervation  will  be  found  in  most  cases  of  consti- 
pation in  old  people,  people  of  sedentary  habits,  and  those  who 
have  little  exercise.  It  is  generally  attended  by  deficient  action 
of  the  skin  and  a  sallow  complexion.  In  such  cases  water  will 
be  found  only  to  weaken  the  digestive  power,  unless  it  can  be 
combined  with  a  different  mode  of  life  and  abundance  of  out- 
door exercise.  Cold  bathing,  however,  cold  against  the  spine 
and  abdomen,  plenty  of  exercise  in  the  open  air,  and  nux  vom- 
ica, will  generally  be  found  to  give  relief. 

In  constipation  dependent  upon  the  large  intestine,  the 
trouble  will  generally  be  found  to  be  due  to  deficient  innerva- 
tion rather  than  to  any  lack  in  the  secretion.  It  is  best  treated 
by  keeping  the  rectum  empty,  by  nux  vomica,  or  belladonna  in 
doses  sufficient  to  cause  dryness  of  the  throat,  and  by  electric- 
ity. The  latter  should  be  in  the  form  of  the  Faradic  current, 
one  pole  being  placed  over  the  spine  and  the  other  passed  up 
and  down  along  the  track  of  the  colon. 

Infantile  constipation  may  be  due,  as  pointed  out  by  Jacobi, 
to  the  disproportionate  length  of  the  sigmoid  flexure.  In  chil- 
dren it  is  not  unusual  to  find  two,  or  even  three,  flexures  in  the 
lower  part  of  the  colon,  in  which  the  fseces  may  remain  until 
they  become  hard  and  friable,  and  when  such  an  anatomical 
formation  is  associated  with  a  deficiency  of  the  intestinal  secre- 
tion, a  very  obstinate  constipation,  and  even  impaction,  may 
result.  In  such  a  case  oatmeal  is  to  be  given  in  preference  to 
tapioca,  rice,  or  barley,  and  with  it  an  abundance  of  water. 
Purgatives  should  never  be  administered  except  in  extreme 
cases,  enemata  being  preferable.8  Faecal  accumulation  is  not 
very  uncommon  in  young  children. 

In  chronic  constipation,  the  patient  should  first  of  all  be  in- 
structed to  have  a  regular  time  for  the  daily  evacuation,  and  the 
best  time  for  this  purpose  is  immediately  after  breakfast.  The 
time  being  fixed,  the  patient  is  to  go  to  the  closet  whether  the 
desire  for  a  passage  be  present  or  not,  and  pass  a  certain  time 
upon  the  commode.     I  generally  recommend  the  time  imme- 

1  Thompson,  New  York  Medical  Record,  May  5,  1877. 

2  New  York  Medical  Record,  September  25,  1880. 


392  DISEASES    OF   THE    RECTUM    AND    ANUS. 

diately  after  the  morning  meal  for  this  purpose,  because  the 
breakfast  itself  often  acts  as  a  stimulant  to  this  function,  espe- 
cially in  those  in  the  habit  of  taking  a  morning  cup  of  coffee. 
If  the  patient  be  a  man  in  the  habit  of  smoking,  the  first  few 
whiffs  of  smoke  often  act  in  the  same  way  ;  and  there  are  many 
men  to  whom  the  morning  cigar  or  cigarette  is  an  essential  to 
the  daily  evacuation.  In  such  a  case  it  must  be  a  very  decided 
opponent  of  the  weed  who  would  object  to  its  continuance  in 
moderation. 

If  the  plain  cold  water  taken  in  the  morning  has  no  effect, 
the  mineral  waters  may  be  tried  in  its  place  with  great  advan- 
tage ;  and  the  patient  may  select  the  one  most  agreeable  to  the 
taste  and  which  most  effectually  accomplishes  the  desired  end. 
The  morning  meal  may  consist  of  whatever  the  patient  most 
desires,  but  a  dish  of  oatmeal  or  coarse  cracked  wheat  and 
milk  should  alwaj^s  be  an  essential  part  of  it. 

A  laxative  bread  may  be  made  of  equal  parts  of  coarse 
Scotch  oatmeal,  whole  wheaten  flour,  and  coarse  ordinary  flour, 
with  yeast  or  baking  powder.  This  may  be  eaten  once  or  twice 
daily.1 

I  have  almost  always  found  that  where  perfect  regularity  in 
the  daily  life  with  regard  to  eating  and  exercise  can  be  estab- 
lished, the  function  of  defecation  will  also  be  performed  regu- 
larly, provided  the  diet  be  plain  and  rather  coarse  in  quality. 
To  have  a  copious,  well-formed  evacuation,  it  is  necessary,  first 
of  all,  that  the  diet  should  be  composed  of  substances  which 
leave  a  considerable  quantity  of  waste,  and  chief  among  these 
are  the  coarser  grains  and  the  vegetables.  In  women  a  certain 
regulated  amount  of  daily  out-door  exercise  should  be  insisted 
upon,  in  spite  of  all  excuses  and  professions  of  disability.  If 
necessary,  this  may  be  small  at  first,  and  gradually  increased  ; 
and  in  a  woman  who  has  lost  the  habit,  and,  perhaps,  almost 
the  power  of  walking,  considerable  tact  and  firmness  on  the 
part  of  the  physician  may  be  required  to  carry  out  this  part  of 
the  treatment,  but  it  will  be  found  to  be  care  well  spent. 

In  addition  to  these  dietetic  and  hygienic  rules,  certain  med- 
ication may  and  often  will  be  found  necessary.  This  should  be 
of  the  mildest  possible  kind  which  will  accomplish  the  object. 
A  pill  which  I  have  found  to  act  very  effectually  and  pleas- 

1  W.  H.  Taylor,  Lancet,  May  31,  1879. 


PRURITUS    ANI.  393 

antly  under  these  circumstances  is  made  after  the  following 
formula : 

# .  Pulv.  aloes  soc gr.  iss. 

Ext.  nucis  vom gr.  ss. 


M. 


Ext.  belladonnas gr. 


One  of  these  should  be  taken  at  bedtime,  and  will  generally 
be  followed  by  an  easy  passage  on  the  following  morning.  If 
this  does  not  wTork  satisfactorily,  various  other  remedies  may 
be  substituted,  amongst  the  best  of  which  is  the  compound  lic- 
orice powder,  the  rhubarb  and  soda  mixture,  or  the  dinner  pill ; 
the  object  being  to  find  one  among  the  many  laxative  prepara- 
tions which,  without  causing  pain  or  diarrhoea,  will  give  an 
easy  and  natural  evacuation  of  the  bowels  once  every  day. 

The  use  of  enemata  for  chronic  constipation  should  not  be 
commenced  till  all  other  means  have  failed,  for  the  reason  that 
when  once  the  bowel  has  become  accustomed  to  this  form  of 
stimulus  it  will  be  found  very  difficult  to  discontinue  its  use. 
In  some  cases,  however,  their  employment  may  be  a  necessity, 
and  they  are  always  much  less  harmful  than  purgatives.  In- 
stead of  the  ordinary  enema  of  soap  and  water,  the  introduction 
of  a  harmless  foreign  body  into  the  rectum  will  sometimes  ex- 
cite peristalsis.  Small  fragments  of  soap  or  of  candles  are  pre- 
ferred by  many  for  this  purpose  to  fluid  injections. 

In  cases  where  enemata  have  lost  their  power  from  prolonged 
use,  my  own  practice  is  to  resort  to  the  use  of  a  long  rectal  tube 
two  or  three  times  a  week  ;  but  this  should  not  be  trusted  to 
the  patient  for  fear  of  accidents.  Most  patients  will  find  it 
impossible  to  introduce  them  easily,  and  will  not  care  to  make 
the  attempt.  With  a  long  flexible  tube  of  small  calibre  a  pint 
or  more  of  water  may  easily  be  thrown  into  the  sigmoid  flexure 
and  colon,  and  the  bowel  be  thoroughly  emptied. 

Another  not  infrequent  cause  of  pruritus  is  derangement  in 
the  function  of  the  liver.  This  may  or  may  not  be  associated 
with  the  constipation  which  we  have  just  considered.  It  must 
be  treated  by  general  dietetic  measures,  the  dilute  mineral  acids, 
occasionally  by  doses  of  podophyllin,  active  out-of-door  exer- 
cise, and  cold  and  friction  applied  to  the  hepatic  region.  In 
women  uterine  disorders  must  be  looked  for  and  cured  before 
very  much  will  be  accomplished  in  the  treatment  of  pruritus  ; 


394  DISEASES    OF   THE    EECTUM    AND    ANUS. 

and  in  women  also  the  urine  must  be  examined  for  sugar  in 
obstinate  cases,  for  diabetes  will  sometimes  give  rise  to  incura- 
ble pruritus. 

In  case  none  of  these  causes  can  be  found  to  account  for  the 
itching,  errors  of  diet  must  be  searched  for,  and  corrected  when 
found.  Anything  like  excess  in  smoking  or  in  alcoholic  drinks 
will  keep  up  the  disease,  and  in  men  these  habits  must  be  care- 
fully regulated  if  indulged  in  at  all.  The  disease  will  some- 
times be  encountered  in  stout  full-blooded  persons  who  live  well 
and  perhaps  incline  to  the  gout,  and  who  show  no  other  signs 
of  disorder.  In  such,  active  exercise  and  plainer  living,  with 
cold  bathing  of  the  part  at  night  and  morning,  and  the  use  of  a 
lotion  of  carbolic  acid,  will  often  effect  a  speedy  cure.  On  the 
other  hand,  the  disease  may  be  present  in  exactly  the  opposite 
class  of  persons,  the  overworked  and  worried  professional  or 
business  man,  and  it  is  in  this  class  of  cases  alone,  where  the 
itching  seems  to  be  purely  a  nervous  symptom,  that  arsenic  is 
indicated.  It  may  be  combined  with  quinine  and  cod-liver  oil, 
and  carried  up  to  its  full  physiological  effect.  As  a  relief  for 
the  intolerable  itchings  at  night,  Allingham  recommends  the 
introduction  of  "a  bone  plug  shaped  like  the  nipple  of  an  in- 
fant's feeding  bottle,  and  with  a  circular  shield  to  prevent  its 
slipping  into  the  bowel."  Its  benefit  is  explained  by  the  pres- 
sure it  exerts  upon  the  terminal  filaments  of  the  blood-vessels 
and  nerves  of  the  anus. 

In  this  way  then  the  physician  must  undertake  the  cure  of 
a  case  of  pruritus  ani ;  and  not  by  the  administration  of  any 
single  lotion  or  ointment  to  allay  the  itching,  which  is  but  the 
symptom  of  some  local  or  general  condition.  In  every  case  the 
cause  must  be  found  and  removed  if  success  in  the  treatment  is 
to  be  gained.  I  know  of  no  disease  of  the  rectum  or  anus  in 
which  there  is  a  better  chance  for  the  practitioner  to  show  his 
general  knowledge  and  skill.  If  a  case  be  undertaken  in  this 
way,  and  the  treatment  be  intelligently  followed  by  both  doctor 
and  patient,  a  cure  may  generally  be  effected  ;  sometimes  in  a 
veiy  few  days,  but  at  others  only  after  prolonged  effort  and 
many  discouragements.  The  prognosis  should,  therefore,  be 
guarded  at  the  outset  lest  the  patient  be  led  to  expect  a  too 
speedy  relief,  and  in  some  cases,  in  spite  of  the  best  of  care,  the 
disease  will  frequently  return  and  the  patient  can  scarcely  at 
any  time  consider  himself  as  perfectly  cured. 


CHAPTER  XV. 

SPASM  OF   THE   SPHINCTER.— NEURALGIA.— WOUNDS.— HEMORRHAGE.— 
RECTAL  ALIMENTATION. 

Spasm  without  other  Disease. — Cases. — Authorities. — Symptoms. — Treatment. — 
Neuralgia. —  Cases. —  Diagnosis. —  Treatment. — Wounds.  —  Complications. — Spon- 
taneous Rupture. — Treatment  of  Wounds. — Haemorrhage  from  the  Rectum. — 
Naevus  of  the  Rectum. — Alimentation.  — Physiology  of  Absorption. — Nutritive 
Enemata. — Nutritive  Suppositories. 

Spasm  of  the  sphincter  without  the  presence  of  any  other  rectal 
affection  is  undoubtedly  rare.  Its  general  character  may  per- 
haps best  be  shown  by  the  citation  of  the  following  cases. 

Case.  Spasm  of  the  Sphincter. — Physician,  aged  twenty- 
eight.  The  patient  was  a  man  decidedly  given  to  thinking 
about  his  own  health,  and  though  generally  well,  not  at  all 
robust.  He  came  to  me  complaining  of  a  sense  of  discomfort 
about  the  rectum,  accompanied  by  difficulty  in  defecation.  The 
discomfort  seldom  amounted  to  actual  pain,  and  he  had  noticed 
that  when  he  was  away  on  his  summer  vacations  he  was  always 
better  and  in  fact  perfectly  well.  Nevertheless,  the  trouble  in 
defecation  had  increased  so  markedly  during  the  past  few 
months  that  he  was  fully  convinced  that  he  was  suffering  from 
actual  stricture. 

An  attempt  at  digital  examination  caused  the  most  exquisite 
suffering,  forcing  the  patient  to  cry  out  in  agony,  and  yet  there 
was  entire  absence  of  any  lesion. 

The  treatment  was  based  upon  the  fact  which  he  had  himself 
noted,  that  when  his  general  condition  was  improved  the  local 
trouble  ceased  ;  and  the  patient  was  cured  by  purely  general 
measures  looking  toward  the  building  up  of  the  system. 

Case.  Spasm  of  the  Sphincter. — Professional  man.  Aged 
thirty. 

In  this  case  also  the  only  symptom  complained  of  was  pain 
on  defecation,  sometimes  severe,  sometimes  slight.  The  history 
given  pointed  so  strongly  toward  the  existence  of  a  fissure  that 


396  DISEASES    OF    THE    RECTUM   AND    ANUS. 

I  etherized  the  patient,  fully  expecting  to  cure  him  by  stretch- 
ing the  sphincter.  He  was  entirely  cured  by  stretching  the 
muscle,  but,  to  my  surprise,  a  most  careful  examination  re- 
vealed no  disease ;  and,  being  dubious  myself  about  the  exis- 
tence of  spasm  without  fissure,  the  examination  was  a  very 
thorough  one.  This  patient  was  also  a  man  of  sedentary  habits 
and  of  rather  a  nervous  character. 

The  following  case  is  taken  from  Syme,  and  is  characterized 
by  him  as  a  remarkable  instance  of  the  affection.1  "I  was 
asked  to  see  a  gentleman,  about  sixty  years  of  age,  who  stated 
that,  a  few  weeks  before,  after  sitting  out  a  long  debate  in  the 
House  of  Commons,  he  had  felt  extreme  difficulty  in  evacuating 
the  bowels,  having  previously  for  several  years  experienced 
more  or  less  uneasiness  from  this  source  ;  that  he  had  consulted 
a  physician  and  surgeon  in  London,  who  prescribed  laxatives 
without  affording  relief  ;  and  that  his  complaint  had  continued 
so  as  at  length  to  confine  him  to  bed.  I  proposed  an  enema, 
which  was  at  once  objected  to  on  the  ground  that  the  anus 
would  not  admit  the  smallest-sized  tube.  Suspicion  being  thus 
excited,  the  anus  was  examined  and  found  to  present  the  char- 
acteristic features  of  spasmodic  stricture.  Having  explained 
my  views  of  the  case,  I  gently  insinuated  the  narrow  sheath  of 
a  bistoury  cache,  which  I  happened  to  have  with  me,  and  then 
expanding  the  blade,  withdrew  it,  so  as  to  make  an  incision  on 
one  side  of  the  orifice.  A  copious  stool  immediately  followed, 
and  the  patient  was  at  once  completely  relieved  from  his  com- 
plaint." 

With  regard  to  this  much  disputed  affection,  a  citation  of 
authorities  may  be  useful.  Syme3  believed  that  spasm  existed 
as  an  independent  condition  without  morbid  change  ;  that, 
though  there  could  be  no  doubt  that  spasm  and  fissure  fre- 
quently existed  together,  it  was  not  reconcilable  with  the  facts 
met  with  in  practice,  that  spasmodic  stricture  was  always  of 
secondary  origin  and  dependent  upon  the  fissure.  He  says : 
"  In  a  considerable  number  of  cases,  I  have  found  the  sphincter 
firmly  contracted  without  any  perceptible  fissure  or  abrasion  of 
the  surface." 

Mayo  describes  spasm  of  the  sphincter  as  a  kind  of  cramp 
which  often  comes  on  suddenty,    sometimes   at  night  daring 

1  Diseases  of  the  Rectum.     Edinburgh,  1838,  p.  138. 

2  Loc.  cit.,  p.  134. 


SPASM    OF    THE    SPHINCTER.  397 

sleep.  The  paroxysms  may  occur  daily  or  two  or  three  times  a 
year;  and  the  attack  may  come  gradually  and  cause  uneasiness 
for  two  or  three  days,  and  then  pass  away,  or  its  coming  and 
going  may  be  sudden.  He  says:  "There  are  cases  in  which 
the  disease  produces  long-continued  and  permanent  suffering  ; 
in  which  the  anus  becomes  permanently  contracted  and  hard- 
ened, constituting,  therefore,  a  permanent  stricture,  and  gen- 
erally combining  both  permanent  and  spasmodic  contraction. 
The  motions  are  passed  with  an  effort  and  with  pain,  and 
all  the  common  symptoms  of  stricture  of  the  rectum  are  pres- 
ent." 

Allingham  *  says  :  "  Spasm  of  the  sphincter  has  been  said  to 
be  the  cause  of  impaction,  but  I  have  more  often  thought  the 
reverse  was  the  case  ;  and  the  impaction  the  cause  of  the  spasm. 
I  must,  however,  acknowledge  that  spasm  is  often  the  cause  of 
the  constipation  which  is  the  forerunner  of  impaction.  In  im- 
paction, spasm  of  the  sphincter  always  exists ;  in  some  in- 
stances to  such  a  degree  that,  when  the  patient  strained,  I  have 
observed  the  anus  protruded  like  a  nipple,  and  an  injection  re- 
turned in  a  fine  stream  as  if  coming  out  of  a  squirt.  I  have 
certainly  met  with  cases  of  idiopathic  spasm  of  the  sphincter 
usually  in  elderly,  nervous  single  women,  and  though  no  im- 
paction was  present,  costiveness  was." 

Quain  2  concludes  that  "where  pain,  brought  on  by  faecal 
evacuations  and  continuing  after  them,  happens  to  be  pres- 
ent, the  fault — the  morbid  condition — is  not  in  the  sphincter, 
but  in  the  skin  or  mucous  membrane  covering  it,  and  that  the 
division  of  the  muscle  is  not  required  in  order  to  remove  the 
patient's  suffering."  In  other  words,  that  spasm  is  always  de- 
pendent upon  fissure.  Boyer3  treats  of  "constriction  with 
fissure"  and  "  constriction  without  fissure." 

Dupuytren*  says:  "The  gravity  of  this  affection  (fissure) 
depends  chiefly  on  the  painful  spasm  of  the  sphincters ;  the 
fissure  is  only  an  accident,  as  is  proved  by  the  existence  of 
painful  spasm  without  fissure,  which,  according  to  well-known 
surgical  authorities,  is  found  in  proportion  to  the  other  of  one 
to  four."     And,  "  the  spasmodic  constriction  is  the  true  lesion, 

1  Op.  cit.,  p.  210. 

2  The  Diseases  of  the  Rectum.     London,  1854,  p.  167. 

3  Traite  des  Maladies  Chirurg.,  etc.,  fourth  edition,  t.  x. ,  p.  139. 

4  Legons  orales  de  Clinique  Chirurg.,  t.  iii.,  p.  284. 


308  DISEASES    OF    THE    RECTUM    AND    ANUS. 

and  the  fissure  only  an  epiphenomenon."  Sir  B.  Brodie1  held 
the  same  views. 

The  symptoms  of  spasm  of  the  sphincter  are  pain  on  defeca- 
tion and  for  a  time  after  ;  more  or  less  uneasiness  about  the 
anus,  especially  when  sitting  ;  fulness  in  the  perineum  ;  often 
more  or  less  trouble  with  the  bladder,  as  shown  by  frequent 
micturition,  sometimes  attended  by  smarting  in  the  urethra  and 
constipation.  The  disease  is  generally  attended  by  exacerba- 
tions and  remissions.  A  digital  examination  of  the  anus  is 
always  painful,  and  the  contraction  may  be  so  great  as  to  leave 
hardly  a  trace  of  the  anal  orifice.  Any  anxiety  or  distress  of 
mind,  a  generally  irritable  nervous  condition,  and  everything 
which  has  a  tendency  to  irritate  the  rectum,  or  the  parts  around, 
will  aggravate  the  complaint.  It  may  easily  be  confounded 
with  the  affection  next  to  be  described,  neuralgia,  but  is  gener- 
ally distinguishable  from  it  by  the  marked  dependence  of  the 
pain  upon  the  act  of  defecation,  which  is  not  seen  in  neuralgia 
without  spasm. 

The  treatment  consists  in  attention  to  the  general  health  of 
the  patient,  in  allaying  any  nervous  excitement,  in  the  admin- 
istration of  a  cathartic  to  empty  the  bowel  when  the  spasm  is 
present,  and  in  anodyne  injections,  such  as,  for  example, 
twenty  drops  of  laudanum  in  an  ounce  of  water.  Suppositories 
may  cause  renewed  irritation.  Even  in  the  more  aggravated 
form,  the  disease  will  often  yield  to  such  measures  as  this,  but 
if  it  does  not,  a  cure  may  always  be  effected  by  forcible  dilata- 
tion of  the  sphincter  under  ether.  If  the  patient  will  not  sub- 
mit to  this,  the  next  best  thing  will  be  found  to  be  the  introduc- 
tion and  retention  of  a  bougie. 

Neuralgia. — Neuralgia  of  the  rectum  is  generally  met  with 
in  nervous  people,  especially  females,  such  as  are  subject  to 
neuralgia  in  other  parts  of  the  body.  The  following  cases  show 
its  general  character. 

Case. — Professional  man,  aged  forty-nine.  The  patient  was 
slight  and  pale  from  sedentary  habits,  but  was  generally  well. 
Thirteen  months  before  consulting  me  he  was  operated  upon  for 
fissure,  and  after  the  operation  he  had  for  some  time  been 
entirely  well,  but  he  now  has  what  he  describes  as  a  dull,  wear- 
ing pain  in  the  rectum,  coming  on  while  at  his  daily  work,  last- 

1  Lectures  on  Diseases  of  the  Rectum.     London  Medical  Gazette,  vol.  xvi.,  p.  26. 


SPASM    OF    THE    SPHINCTER.  399 

ing  a  longer  or  shorter  time,  sometimes  all  day,  but  generally 
passing  away  after  lie  has  reached  his  home  and  become  quiet 
and  rested.  He  has  noticed  that  the  pain  has  a  direct  connec- 
tion with  the  state  of  his  general  heath,  and  that,  when  he  is 
away  from  his  work  and  rusticating,  he  is  entirely  free  from  it. 
The  pain  is  no  greater  at  the  time  of  defecation  than  at  any 
other,  and  is  never  so  severe  as  to  be  unbearable.  A  careful  ex- 
amination of  the  part  failed  entirely  to  show  any  lesion. 

Case. — Woman,  aged  sixty-five,  married.  This  patient  had 
been  treated  for  fissure,  for  ulceration,  and  for  coccygodynia, 
and  had  ref  used  to  submit  to  excision  of  the  coccyx.  Her  gen- 
eral health  was  fair,  but  there  was  decided  gastro-intestinal  dis- 
turbance. The  pain  of  which  she  complains  has  been  present 
for  about  eighteen  'months.  She  suffers  chiefly  when  sitting, 
sometimes  finds  it  impossible  to  lie  upon  her  back,  and  is  apt 
to  have  a  sharp  twinge  when  she  starts  suddenly  from  her  chair. 
The  pain  is  no  worse  at  defecation,  is  not  increased  by  pressure 
upon  or  movement  of  the  coccyx,  and  is  entirety  unconnected 
with  any  lesion  of  the  rectum  or  anus.  The  greatest  sensitive- 
ness to  touch  seemed  to  be  located  well  within  the  sphincter, 
upon  the  posterior  wall  of  the  bowel.  There  was  enlargement 
of  the  womb  and  misplacement. 

From  these  cases,  which  are  both  good  examples  of  mild 
forms  of  the  affection,  it  is  evident  that  the  disease  may  vary 
greatly  in  its  severity.  In  some  persons  it  will  cause  the  same 
suffering  as  the  most  intense  neuralgia  elsewhere.  The  pain  is 
apt  to  be  paroxysmal,  but  may  be  continuous,  and  is  indepen- 
dent of  the  act  of  defecation.  In  cases  of  well-marked  period- 
icity, a  malarial  element  should  be  looked  for,  and  the  disease 
may  be  a.  manifestation  of  the  gouty  diathesis.  In  the  former 
case,  quinine,  and  in  the  latter,  colchicum  maybe  of  the  greatest 
service.  In  all  other  cases  the  treatment  will  often  be  found 
unsatisfactory,  and  is  to  be  conducted  on  general  principles. 
The  first  care  should  be  for  the  general  health,  the  second  for 
the  regularity  of  the  bowels,  and  after  this,  local  applications 
of  cold  water,  ointment  of  belladonna  (3  ]'•- !  j.),  and  blistering 
over  the  sacrum  may  be  tried.  Besides  this  local  treatment 
the  case  must  be  managed  exactly  as  would  be  a  case  of  neu- 
ralgia in  any  other  part. 

The  diagnosis  from  coccygodynia  and  from  spasm  must  both 
be  made  with  care. 


400  DISEASES    OF   THE    RECTUM    AND    ANUS. 

Wounds  of  the  Rectum. — Wounds  of  the  rectum  may  be 
either  contused  and  lacerated,  or  incised.  The  latter  most  fre- 
quently result  from  surgical  operations,  and  may  be  intention- 
ally inflicted,  as  in  the  operations  for  fistula  or  for  the  removal 
of  tumors,  or  the  result  of  accident,  as  in  the  operation  for 
stone.  Contused  and  lacerated  wounds  are  generally  the  result 
of  accident,  and  perhaps  the  most  frequent  cause  of  such  an  in- 
jury is  the  perforation  of  the  bowel  with  an  enema  tube,  a 
bougie,  or  a  urethral  sound.  The  gravity  of  this  accident 
will  depend  upon  two  factors — whether  the  perforation  of  the 
bowel  is  above  the  peritoneum,  and  whether  the  enema  has 
been  deposited  in  the  perirectal  tissues.  The  latter  complica- 
tion will  be  followed  by  abscess  and  peritonitis,  and  will  re- 
sult either  in  death  or  in  stricture  and  fistula.  If  the  wound 
be  uncomplicated  by  the  injection,  the  mere  puncture  may 
heal  spontaneously.  It  is  oblique  from  below  upward,  and 
this  greatly  favors  spontaneous  healing  without  faecal  extra- 
vasation. 

Esmarch  has  met  with  four  cases  of  this  injury,  none  of 
which  were  fatal  though  attended  by  much  local  trouble.  Vel- 
peau  describes  eight  cases,  six  of  which  ended  fatally.  Passa- 
vant  observed  five  cases,  one  fatal.  Chomel  has  had  two  fatal 
results.  There  are  two  preparations  in  St.  Bartholomew's  Hos- 
pital showing  the  results  of  this  accident,  one  in  a  man,  the 
other  in  a  child  ten  years  of  age  (Esmarch). 

Besides  these  most  common  injuries,  many  others  may  be 
enumerated.  The  person  may  fall  upon  a  sharp  body,  as  the 
point  of  an  umbrella  (Bushe1),  may  be  caught  upon  the  horn  of 
an  animal  (GJ-undrum,3  Ashton),  or  may  be  impaled  upon  a  spike 
(Esmarch  :,j. 

In  such  cases,  the  accident  may  be  immediately  fatal  from 
collapse,  and  the  wound  in  the  rectum  may  be  complicated  by  a 
wound  of  the  peritoneum,  or  of  any  of  the  adjacent  organs. 
The  body  which  has  done  the  injury  may  also  be  so  firmly  im- 
planted as  to  require  great  force  and  an  anaesthetic  for  its  re- 
moval. 

The  rectum  is  not  infrequently  lacerated  in  childbirth,  and 
although  such  wounds  are  generally  of  slight  extent,  Bushe4 
relates  a  case  in  which  the  child's  head  was  passed  through  the 

1  Op.  cit.,  p.  80.  '■'Detroit  Lancet,  October,  1879. 

'Op.  cit.,  p.  43.  'Op.  cit.,  p.  80. 


SPASM    OF    THE    SPniNCTEPw  401 

arms.  It  has  also  happened  that  in  a  violent  effort  to  expel  a 
mass  of  hard  faeces,  the  rectal  wall  has  given  away.  Mayo  '  re- 
lates one  such  case  in  a  woman  of  forty,  in  whom  the  rupture 
was  in  the  recto-vaginal  septum,  about  two  inches  within  the 
bowel.  Ashton2  reports  a  similar  case,  and  Bushe3  another. 
Such  a  rupture  may  be  either  vertical  or  transverse,  will  be 
marked  by  sharp  pain  at  the  moment  of  the  accident,  and  will 
be  followed  by  a  discharge  of  blood.  It  is  doubtful  whether  it 
ever  occurs  without  previous  disease  of  the  wall  of  the  bowel. 

The  consideration  of  gunshot  wounds  comes  more  properly 
within  the  scope  of  military  surgery.  They  are  always  compli- 
cated with  injuries  of  other  parts,  and  are  generally  fatal  from 
extravasation  of  urine  or  faeces. 

The  complications  which  may  attend  a  wound  of  the  rectum 
have  already  been  hinted  at.  They  are  hemorrhage,  either 
primary  or  secondary  ;  faecal  infiltration  ;  purulent  infiltration  ; 
peritonitis  ;  emphysema  ;  hernia  ;  invagination  ;  and  later,  stric- 
ture and  fistula.  When  faeces  are  forced  out  of  the  rectum 
into  the  adjacent  tissue,  diffuse  inflammation  and  gangrene  will 
probably  result,  and  the  condition  must  at  once  be  met  by  free 
incisions  and  free  drainage,  as  has  been  described  in  the  chapter 
on  abscess.  The  danger  of  faecal  infiltration  may  be  lessened 
by  a  diet  which  shall  prevent  fluid  passages,  and  by  the  free  use 
of  opium.  A  dilatation  or  a  free  division  of  the  sphincter  is 
also  to  be  recommended,  so  that  a  free  outlet  may  be  accorded 
to  the  contents  of  the  bowel. 

Emphysema,  as  a  result  of  a  perforation,  is  generally  con- 
fined to  the  perinaeum,  but  may  be  diffuse.4  It  is  very  apt  to 
be  fatal  from  diffuse  inflammation  and  septicaemia,  due  to  the 
putrid  nature  of  the  gas,  and  is  to  be  met  by  free  incisions. 

Wounds  of  the  bladder  or  urethra  communicating  with  the 
rectum  are  to  be  met  by  providing  for  the  free  issue  of  the 
urine.  This  may  be  done  by  catheterism,  by  aspiration,  or  by 
free  division  of  the  sphincter. 

Where  none  of  these  complications  exist,  a  fresh  wound  of 
the  rectum  may  close  by  first  intention,  and  an  effort  should 
always  be  made  to  secure  this  by  rest  in  bed,  by  emptying  the 
bowel,  and  keeping  it  empty  by  frequent  washings  with  water, 
and  by  the  use  of  opium.     Healing  by  granulation  will,  how- 

•Op.  cit.,  p.  13.  20p.  cit.,  p.  152. 

3 Op.  cit.,  p.  69.  *  Lancet,  January,  p.  89.     1860. 

26 


402  DISEASES    OF    THE    RECTUM    AND    ANUS. 

ever,  be  the  rule.  In  some  cases,  such,  for  example,  as  lacera- 
tion in  childbirth,  sutures  may  be  at  once  applied. 

HcBmorrliage. — Bleeding  from  the  rectum,  as  has  already 
been  shown,  is  a  very  common  symptom  of  disease  of  the  part 
and  is  usually  easily  controlled  ;  but  the  following  cases  illus- 
trate exceedingly  rare  forms  of  trouble. 

Case.  Ncevus  of  the  Rectum. — Mr.  E.  T.  Barker  reported, 
at  a  meeting  of  the  Royal  Medical  and  Chirurgical  Society,1  the 
following  case  of  naevus  of  the  rectum  in  an  adult,  which 
proved  fatal  from  repeated  haemorrhages.  The  case  was  the 
only  one  known  to  the  author,  though  in  the  discussion  Mr. 
Howard  Marsh  spoke  of  another  in  a  girl,  aged  ten,  under  his 
care,  in  the  Children's  Hospital.  In  Mr.  Barkers  case  the 
earliest  symptom  was  an  attack  of  diarrhoea  accompanied  by 
great  loss  of  blood,  and  the  whole  history  of  the  case  was 
marked  simply  by  these  two  symptoms  alternating  with  occa- 
sional constijDation,  there  being  no  particular  pain  or  discharge 
at  any  time.  The  diagnosis  was  made  by  artificial  light  and  a 
large  vaginal  speculum.  The  mucous  membrane  of  the  bowel 
was  seen  to  be  marked  by  smooth  longitudinal  folds,  mottled 
with  a  peculiar  purplish  tint,  and  upon  these  were  three  shallow 
ulcers  from  which  the  blood  flowed  freely.  The  patient  died 
finally  from  repeated  haemorrhages,  and  the  autopsy  revealed 
a  thickened  condition  of  the  lower  four  inches  and  a  half  of  the 
bowel,  which  was  due  to  the  naevoid  growth,  on  the  rugae  of 
which  were  the  three  shallow  ulcers  mentioned. 

In  Mr.  Marsh's  case  the  child  had  suffered,  since  the  age  of 
two,  from  repeated  severe  haemorrhages.  Examination  revealed 
a  naevoid  growth  completely  surrounding  the  lower  end  of  the 
bowel.  This  was  treated  by  several  applications  of  Paquelin's 
cautery,  which  relieved  but  did  not  cure  the  condition. 

"While  speaking  of  haemorrhage  from  the  rectum,  it  may  be 
well  to  refer  to  two  cases  of  bleeding  which  have  recently  been 
reported  in  the  New  York  Medical  Record.  The  first  (New  York 
Medical  Record,  September  27,  1879)  is  by  Dr.  Manley,  of  Law- 
rence, Mass.  It  occurred  in  an  apparently  healthy  infant,  three 
days  old,  and  ended  fatally.  A  post-mortem  examination 
showed  that  the  blood  came  from  an  opening  in  one  of  the 
rectal  veins  about  three  inches  from  the  anus,  which  admitted 
of  the  introduction  of  a  bristle. 

1  The  Lancet,  April  14,  1883. 


SPASM    OF    THE    SPHINCTER.  403 

The  second  case  (New  York  Medical  Record,  January  17, 
1880)  is  reported  by  Dr.  McGuire,  of  Salem,  Ohio,  and  is  very 
similar,  the  child  being  about  the  same  age.  Notwithstanding- 
suitable  treatment  by  styptic  applications,  this  also  terminated 
fatally  ;  but  no  autopsy  was  obtained,  and  the  precise  source 
of  the  haemorrhage  is  unknown. 

Alimentation  by  the  Rectum. — The  fact  that  certain  sub- 
stances may  be  absorbed  into  the  general  circulation  through 
the  mucous  membrane  of  the  rectum  has  been  abundantly 
proved  by  physiological  experiment  and  clinical  experience. 
The  close  anatomical  resemblance  between  the  inverted  folli- 
cles of  the  rectum  and  the  intestinal  villi  render  an  analogy  in 
function  extremely  probable  without  experimental  proof  ;  but 
such  proof  is  easily  obtainable.  A  solution  of  salt,  in  the  pro- 
portion of  one  part  to  eighty  of  water,  injected  into  the  rectum, 
will  disappear  completely  in  the  course  of  an  hour — so  com- 
pletely that  an  evacuation  at  the  end  of  that  time  will  be  found 
to  contain  no  more  than  the  usual  quantity.1  The  fluid  extract 
of  rhubarb  may  be  detected  in  the  urine  in  about  an  hour  after 
being  injected  into  the  rectum,  by  the  characteristic  red  color 
caused  by  the  addition  of  caustic  potash.2 

Bouisson,3  after  injecting  beef-tea  into  the  rectum,  found 
the  lacteals  charged  with  fluid.  Savory,4  in  his  experiments  on 
the  relative  rapidity  of  this  absorption  by  the  stomach  and  rec- 
tum, found  that  strychnia  in  solution  acts  more  quickly  by  the 
rectum,  but  that  in  powder  the  relation  was  reversed.  Quinine 
should  be  given  in  larger  doses  by  the  rectum  than  by  the 
mouth,  while  chloral  and  belladonna  are  readily  absorbed  by 
the  former.  Curare,  on  the  contrary,  acts  more  quickly  by  the 
rectum  (CI.  Bernard).  Cubebs  and  copaiba  both  act  equally 
well  by  the  rectum  ;  and  water  charged  with  sulphuretted  hy- 
drogen gas  is  rapidly  eliminated  in  the  dog  by  respiration,  as 
may  easily  be  proved  by  the  usual  test  with  a  salt  of  lead. 

The  fact  of  absorption  being  admitted,  the  next  question  is 
as  to  the  power  of  digestion  before  absorption,  and  upon  this 

1  Liebig  :  Animal  Chemistry. 

2  Smith :  Supplementary  Rectal  Alimentation,  and  Especially  by  Defibrinated 
Blood,  as  Applicable  to  a  Large  Range  of  Cases  in  which  Nutritive  Enemata  have  not 
heretofore  been  Employed.  Read  before  the  New  York  Academy  of  Medicine,  Feb- 
ruary 20,  1879. 

3  Diet.  Encyc,  Art.  Rectum.  *  Gaz.  Med.,  1864. 


404  DISEASES    OF    THE    RECTUM    AND    ANUS. 

point  there  has  been  considerable  discussion  of  late,  and  much 
difference  of  opinion. 

The  theory  that  the  follicles  of  Lieberkuhn  may  take  on  a 
vicarious  action,  and  secrete  a  digestive  fluid  under  the  stimulus 
of  albuminous  food  placed  in  contact  with  the  epithelium,  has 
its  upholders,  but  has  never  been  absolutely  proved.1 

Another  theory  is  that  food  introduced  into  the  rectum  ex- 
cites secretion  by  the  gastric  and  intestinal  follicles,  and  that, 
in  the  absence  of  food  in  the  stomach,  the  digestive  fluids  thus 
secreted  pass  down  into  the  rectum  and  there  act  upon  the  in- 
jected materials.2 

Still  another  theory  is  that,  instead  of  digestive  fluids  de- 
scending to  act  upon  the  food,  the  latter  ascends  to  be  acted 
upon  by  the  fluids  in  the  small  intestine,  and  is  there  fitted  for 
absorption.3  This  theory  has  grown  out  of  certain  facts  which 
have  recently  come  to  light  regarding  the  reversed  peristaltic 
power  of  the  bowel.  Injected  matters,  such  as  blood  and  milk 
colored  with  madder,  may  be  found,  on  post-mortem  examina- 
tion, evenly  distributed  over  the  coats  of  the  intestine  for  a 
considerable  distance  above  the  rectum,  and  this  is  in  itself  a 
simple  argument  in  proof  of  a  reversed  action  of  the  bowel. 
But  there  are  are  many  stronger  ones.  Dr.  Battey,  in  an  arti- 
cle on  the  "Permeability  of  the  entire  alimentary  canal  by 
enema,  with  some  of  its  surgical  applications,"  4  details  some 
experiments  of  his  own  by  which  he  succeeded,  in  the  cadaver, 
in  passing  an  injection  from  the  rectum  through  the  whole 
length  of  the  digestive  canal,  and  out  of  the  mouth.     He  also 

1  C.  H.  Stowell :  Is  Food  Digested  in  the  Rectum  ?  The  Medical  Advance,  Janu- 
ary, 1879. 

*  A.  Flint:  Trans.  N.  Y.  Acad,  of  Med.,  February  20,  1879,  and  "Cases  Illustrative 
of  Rectal  Alimentation,  with  Remarks,"  Amer.  Practitioner,  January,  1878. 

3  H.  F.  Campbell :  Rectal  Alimentation  in  the  Nausea  and  Inanition  of  Pregnancy 
— Intestinal  Inhaustion  an  Important  Factor  and  the  True  Solution  of  its  Efficiency. 
Trans.  Gynaecological  Soc. ,  1879. 

4  Virg.  Med.  Monthly,  vol.  v.,  1878.  Dr.  Battey  makes  a  claim  to  priority  in  having 
established  the  "  entire  permeability  of  the  canal  to  enema."  which,  though  no  doubt 
perfectly  just  as  far  as  his  own  experiments  go,  is  refuted  in  the  Med.  and  Surg.  Hist, 
of  the  War,  Med.,  vol.  ii.,  p.  836,  foot-note,  by  the  following  references: 

A.  Guaynerius:  Tractatus  de  fluxibus.  Cap.  2,  Lyons  Ed.,  1534.  History  of  a 
man  who  vomited  suppository  placed  in  the  rectum. 

J.  Matthias  de  Gradibus :  Practicia  de  iEgritudinibus  stomaci.  Cap.  5,  devomitu, 
fol.  213,  Venice  Ed.,  1502  ;  History  of  girl  who  constantly  vomited  her  suppositories, 
even  after  they  had  been  tied  with  a  string  to  keep  them  in  the  rectum. 

Morgagni,  references  to  numerous  similar  cases. 


SPASM    OF    THE    SPHINCTER.  405 

gives  certain  cases  in  which  what  he  has  accomplished  on  the 
dead  subject  has  been  done  by  nature  in  the  living  patient.  In 
this  way  he  accounts  for  the  undoubted  fact  that  patients  will 
often  complain  of  tasting  in  the  mouth  a  substance  like  castor- 
oil  which  has  been  administered  by  the  rectum  ;  and  for  the 
fact  that  the  ingredients  of  an  enema,  or  a  suppository,  have 
occasionally  been  actually  vomited.  Dr.  Harris,  of  Milledge- 
ville,  Ga.,1  has  recentty  reported  a  case  in  which  clear  beef-tea 
enemata  were  vomited  after  an  operation  for  ovariotomy. 

Jaccoud  records  a  case  of  faecal  vomiting  which  occurred  in 
his  wards  at  the  Lariboisiere,  in  1867,  in  a  young  woman  who 
was  admitted  with  hysterical  convulsions.  For  eight  days  this 
person,  at  least  once,  and  sometimes  twice,  in  the  twenty-four 
hours,  vomited  veritable  faeces,  dense,  solid,  cylindrical,  of  a 
brown  color,  and  with  the  normal  fsecal  odor,  coming  evidently 
from  the  large  intestine.  Jaccoud  witnessed  the  act  himself, 
and  so  also  did  Dieulafoy,  and  he  characterizes  it  as  actual 
defecation  by  the  mouth.  Apart  from  the  passing  disgust  which 
followed  the  act,  the  patient  ate  as  usual,  and  continued  in  her 
ordinary  health,  except  in  the  absence  of  normal  action  of  the 
bowels.  All  possibility  of  deception  seems  to  have  been  rigor- 
ously excluded.  Within  a  fortnight  the  woman  was  seized 
with  grave  typhoid  fever  and  died.  Careful  examination  of  the 
body  disclosed  no  mechanical  obstruction  whatever  in  the  intes- 
tinal canal.     The  ileo-caecal  valve  was  normal.2 

Fsecal  vomiting  is  not  necessarily  a  sign  of  intestinal  obstruc- 
tion, as  has  been  shown  by  Leduc.3  In  seventeen  cases  which  he 
observed  there  was  no  obstruction.  He  believes  it  to  be  simply 
a  sign  of  paralysis  of  the  bowel,  either  reflex  in  origin  or  due 
to  an  extension  of  inflammation  from  the  serous  surface  to  the 
muscular  tunic.  This  he  thinks,  taken  with  the  action  of  the 
diaphragm,  is  sufficient  to  account  for  the  reflux  of  the  faeces 
into  the  stomach  and  their  rejection  by  the  mouth  in  an  effort  at 
vomiting. 

By  one  of  these  three  explanations  it  is  attempted  to  over- 
come the  obvious  physiological  objections  to  rectal  alimenta- 
tion which  arise  from  the  facts  that  albumen  is  not  diffusible,  or 

1  Quoted  by  Campbell,  loc.  cit. 

2  Van  Buren  :  On  Phantom   Stricture,   etc.     Amer.   Journal  Med.   Sci.,  October, 
1879. 

3  Du  Vomissement  Fecaloi'de  dans  les  affections  du  peritoine  (sans  obstacle  meca- 
nique  au  cours  des  matieres).     These  de  Paris,  1881. 


406  DISEASES    OF    THE    EECTUM    AND    ANUS. 

if  so  at  all,  only  very  slowly  and  in  very  small  quantity  ;  and 
that  to  be  absorbed  it  must  first  be  changed  by  digestion  into 
albuminose.  Another  and  very  practical  way  of  overcoming  the 
obstacle  has  been  suggested  by  Dr.  Chadwick,1  which  consists 
in  placing  the  enema  directly  into  the  small  intestine  by  means 
of  an  aspirator — a  procedure  which  might  be  considered  as  not 
unattended  with  danger.  Michel2  has  found  the  obstacle  in- 
surmountable and  has,  therefore,  come  to  a  conclusion  unfavor- 
able to  the  absorption  of  the  nutritive  matter  of  the  substances 
injected. 

The  theoretical  difficulty  of  the  digestion  of  albuminoid  sub- 
stances has  been  practically  overcome  in  a  very  simple  manner, 
which  is  nothing  more  or  less  than  artificially  digesting  such 
substances,  either  before  or  after  their  administration,  by  mix- 
ing with  them  a  certain  quantity  of  pepsin  or  freshly  prepared 
pancreas.  Catillon 3  has  performed  the  following  instructive  ex- 
periments in  this  connection.  He  fed  two  dogs  for  two  months 
with  injections  of  eggs.  The  first  had  eggs  only  and  lived  with 
difficulty  and  with  considerable  loss  of  weight ;  the  second  had 
glycerine  and  pepsin  mixed  with  the  eggs  and  lived  in  an  ap- 
parently normal  manner,  the  weight  and  temperature  remain- 
ing constant.  After  thirty-seven  days  the  pepsin  was  stopped, 
when  the  animal  began  to  lose  weight  and  the  temperature  fell 
3°  Fahr.  The  conclusion  is  plain  that  for  nutrition  the  diges- 
tive ferments  must  be  associated  with  the  food,  or  in  other 
words,  that  they  must  be  transformed  into  peptones.  In  an- 
other series  of  experiments  the  same  author  has  demonstrated 
that  the  same  result  is  obtained  by  peptones  prepared  artifi- 
cially. 

There  would  seem  to  be  no  doubt,  in  the  light  of  the  abun- 
dant clinical  evidence  which  has  now  been  accumulated,  that 
life  may  be  supported  indefinitely,  without  loss  of  weight,  by 
the  proper  administration  of  properly  prepared  enemata.  Flint  * 
refers  to  one  case  in  which  life  was  so  sustained  for  fifteen 
months,  and  in  which  the  feeding  had  been  mainly  of  this  kind 
for  five  years. 

For  the  convenience  of  the  practitioner,  the  following  for- 


1  Amer.  Jour,  of  Obstet.,  viii.,  November,  1875.  2  Gaz.  Hebdom.,  1879. 

3  Meeting  of  French  Ass.  for  Advancement  of  Science  at  Rheims,  1880.     Abstract 
in  Brit.  Med.  Jour.,  p.  485,  September  18,  1880. 

4  New  York  Med.  Record,  p.  56,  1878. 


SPASM    OF   THE    SPHINCTER.  407 

mulse  for  nutritive  enemata  have  been  collected.  The  first  is 
the  one  used  by  Mayet '  and  approved  by  Brown-Sequard.2 
Take  of  fresh  pancreas  of  the  ox  from  one  hundred  and  fifty  to 
two  hundred  grammes,  and  of  lean  meat  from  four  hundred  to 
five  hundred  grammes.  Bruise  the  pancreas  in  a  mortar  with 
tepid  water  at  a  temperature  of  37°  C,  and  strain  through  a 
cloth.  Chop  the  meat  and  mix  it  thoroughly  with  the  fluid 
which  has  thus  been  strained  after  separating  all  the  fat  and 
tendinous  portions.  Add  the  yolk  of  one  egg.  Let  stand  for 
two  hours  and  administer  at  the  same  temperature  after  having 
cleansed  the  rectum  with  an  injection  of  oil.  This  quantity  is 
estimated  by  Brown-Sequard  to  be  sufficient  for  twenty-four 
hours'  nourishment,  and  should  be  administered  in  two  doses. 

Where  the  pancreas  cannot  be  readily  obtained,  the  follow- 
ing formula  may  be  found  useful.3  To  a  basin  of  good  beef-tea 
add  half  a  pound  of  lean,  raw  beefsteak  pulled  into  shreds. 
At  about  the  temperature  of  the  body  add  one  drachm  of  fresh 
pepsin  and  half  a  drachm  of  dilute  hydrochloric  acid.  Place 
the  mixture  before  the  fire  and  let  it  remain  for  four  hours,  stir- 
ring frequently.  The  heat  must  not  be  too  great  or  the  artifi- 
cial digestive  process  will  be  stopped  altogether.  It  is  better 
to  have  the  mixture  too  cold  than  too  hot.  Sometimes  a  little 
more  pepsin  may  be  needed,  which  may  be  ascertained  by  stir- 
ring with  a  spoon.  If  alcohol  is  to  be  given,  it  should  be  added 
at  the  last  moment.  Eggs  may  also  be  added,  but  should  be 
previously  well  beaten.  This  preparation  is  said  to  be  well 
borne  for  a  long  time. 

The  formula  of  the  late  Dr.  Peaslee  was  as  follows :  Crush 
one  pound  of  beef-muscle  fine,  and  add  to  it  one  pint  of  cold 
water.  Allow  it  to  macerate  three-quarters  of  an  hour  and 
then  raise  gradually  to  the  boiling-point.  Allow  it  to  boil  two 
minutes  and  no  more.  The  favorite  injection  of  Dr.  Flint  is 
milk  §ij.,  whiskey  §ss.,  and  the  half  of  an  egg.  This  head- 
ministers  every  three  hours,  day  and  night.  But  these  simple 
enemata,  no  matter  what  their  merits  may  be  or  may  have 
been  in  the  past  (and  we  are  inclined  to  wonder  whether  all  at- 
tempts at  alimentation,  before  the  admixture  of  pancreas  was 
thought   of,   have  been  as   useless  as  Catillon's  experiments 

1  Gaz.  Hebdom.,  November  21,  1879.  2  Ibid.,  November  14,  1879. 

3  Rennie  :  Case  of  severe  cut  throat ;  with  some  remarks  on  the  administration  of 
nutritive  enemata.     Lancet,  October  22,  1881. 


408  DISEASES    OF   THE   RECTUM    AND    ANUS. 

would  indicate),  are  now  generally  replaced  by  those  of  artifi- 
cialty  digested  meat. 

In  the  }rear  1878  many  experiments  were  made  in  New  York 
with  defibrinated  blood  as  an  enema,  and  the  conclusions 
reached  were  embodied  by  Dr.  A.  H.  Smith  in  the  paper  al- 
ready referred  to,  and  were  as  follows  : 

"  1.  That  defibrinated  blood  is  admirably  adapted  for  use  in 
rectal  alimentation. 

"2.  That  in  doses  of  sixty  to  one  hundred  and  eighty 
grammes  (two  to  six  ounces)  it  is  usually  retained  without  any 
inconvenience,  and  is  frequently  so  completely  absorbed  that 
very  little  trace  of  it  can  be  discovered  in  the  dejections. 

"3.  That  administered  in  this  way  once  or  twice  a  day  it 
produces,  in  about  one-third  of  the  cases,  for  the  first  few  days, 
more  or  less  constipation  of  the  bowels. 

"4.  That  in  a  small  proportion  of  cases  the  constipation 
persists,  and  even  becomes  more  decided  the  longer  the  enemata 
are  continued. 

"5.  That  in  a  very  small  percentage  of  cases  irritability  of 
the  bowels  attends  its  protracted  use. 

"6.  That  it  is  a  valuable  aid  to  the  stomach  whenever  the 
latter  is  inadequate  to  a  complete  nutrition  of  the  system. 

"7.  That  its  use  is  indicated  in  all  cases  not  involving  the 
large  intestines,  and  requiring  a  tonic  influence  which  cannot 
readily  be  obtained  by  remedies  employed  in  the  usual  way. 

"8.  That  in  favorable  cases  it  is  capable  of  giving  an  im- 
pulse to  nutrition  which  is  rarely,  if  ever,  obtained  from  the 
employment  of  other  remedies. 

"9.  That  its  use  is  wholly  unattended  by  danger." 

However  useful  and  nutritious  these  enemata  may  be,  there 
is  one  practical  objection  to  them  which  I  have  occasionally  met 
and  have  been  unable  to  overcome.  The  sight  of  the  blood, 
its  administration,  and  its  subsequent  voiding  are  not  calcu- 
lated to  impress  the  mind  of  a  nervous  and  delicate  lady  pleas- 
antly— on  the  contrary,  they  sometimes  excite  the  most  pro- 
found disgust. 

No  one  form  of  enema  should  be  continued  for  too  long  a 
linn,  and  as  a  rule,  patients  will  be  found  to  thrive  best  upon 
an  alternating  diet  of  milk  and  egg,  with  preparations  of  beef 
and  pancreas,  alcohol  being  given  as  it  is  indicated.  The  rec- 
luni  proper  will  seldom  accommodate  more  than  six  ounces  of 


SPASM    OF    THE    SPHINCTER.  409 

fluid,  and  this  is  the  usual  quantity  for  an  enema  ;  but  the  sig- 
moid flexure  will  hold  much  more  than  this  ;  and  for  myself,  I 
much  prefer  what  may  be  called  the  colonic  to  the  rectal  method, 
because  the  injections  are  better  retained,  cause  less  irritation,  ■ 
may  be  given  in  larger  quantity,  and  hence  need  not  be  so 
often  repeated.  The  best  apparatus  for  this  purpose  is  a  small- 
sized,  soft-rubber,  flexible  rectal  bougie,  the  end  of  which  will 
accommodate  the  smallest  end-piece  of  the  ordinary  Davidson 
syringe.  This  should  be  well  oiled,  and  the  fluid  to  be  injected 
should  be  forced  through  it  once  or  twice  till  it  is  well  warmed 
and  the  air  is  entirely  forced  out.  The  tube  is  introduced  into 
the  sigmoid  flexure  after  the  syringe  has  been  connected.  In 
this  way,  all  over-distention  of  the  rectum  and  consequent 
desire  of  the  patient  to  immediately  evacuate  what  has  been  ad- 
ministered is  avoided.  The  enema  should  be  administered 
slowly,  and  by  the  physician  himself  rather  than  the  nurse  or 
relative  of  the  patient,  for  the  operation  is  one  requiring  judg- 
ment and  skill,  and  on  the  success  of  the  method  depends  the 
life  of  the  patient  in  most  cases.  It  is  always  well  to  empty  the 
bowel  by  a  simple  enema  before  administering  nutriment,  at  least 
once  a  day.  With  proper  care  in  using  the  syringe,  the  rectum 
and  sigmoid  flexure  will  generally  be  found  to  submit  kindly 
to  this  method  of  treatment ;  but  when  once  they  become  irri- 
table, unless  the  injections  can  be  intermitted  for  a  day  or  so 
and  suppositories  of  opium  be  substituted,  the  treatment  is 
practically  at  an  end.  In  a  few  cases  I  have  succeeded  in  re- 
establishing a  tolerance  by  rest  and  careful  treatment,  but  it  is 
much  better  so  to  manage  the  case  from  the  first  that  no  irrita- 
tion be  excited.  An  enema,  for  this  reason,  should  never  be 
administered  at  a  lower  temperature  than  that  of  the  body. 

Dr.  Spencer  *  has  described  a  suppository  which  he  recom- 
mends in  the  place  of  enemata.  It  consists  of  the  extracted 
product  of  artificially  digested  meat,  from  which  the  insoluble 
matter  has  been  removed,  mixed  with  a  little  wax  and  starch. 
Twenty  ounces  of  meat  thus  prepared  may  be  made  into  five 
suppositories,  one  of  which  should  be  given  every  four  hours. 

1  Practitioner,  February,  1882. 


INDEX. 


Abscess,  90 

cure  without  fistula,  103 

deep,  93 

deep,  causes  of,  94 

due  to  stricture,  279 

early  incision  of,  102 

horseshoe,  100 

pelvic,  97 

residual,  95 

simulating  distended  bladder,  99 

symptoms  of  superficial,  92 

treatment  of  superficial,  92 

varieties  of,  91 
Absence  of  anus,  38 

of  large  intestine,  44 

of  rectum,  43 
Absorption  by  rectum,  403 
Acquired  strictures,  272 
Adenoma,  malignant,  320 

semi-malignant,  320 

simple,  320 
Adenomatous  polypus,  216 
Alimentation,  rectal,  403 
Allingham's  ligature  carrier,  117 

operation,  150 

operation  compared  with  Smith's,  155 

operation,  objec  ions,  152 

spring-scissors,  120 
Ampulla,  2 

Amussat,  operation  of,  47 
Anatomy,  minute,  of  rectum,  8 

of  anus,  5 

of  external  sphincter,  12 

of  internal  sphincter,  12 

of  ischio-coccygeus,  13 

of  levator  ani,  13 

of  recto-coccygeus,  12 

of  retractor  recti,  12 

of  rectal  hernia,  198 

of  rectum,  1 

of  tensor  fasciae  pelvis,  12 

of  third  sphincter,  23 

of  transversus  perinei,  15 
Ano-rectal  syphiloma,  229,  260 
Anus,  absence  of,  38,  40 

anatomy  of,  5 

attempts  to  establish,  after  colotomy, 
53 

closed  by  diaphragm,  37 

development  of,  in  embryo,  30 

erectile  tissue  of,  5 

examination  of,  59 

imperforate,  colotomy  for,  48 

malformations  of,  36 


Anus,  muscles  of,  11 

normal,  rectum  imperforate,  39 
Apparatus  for  injections,  66 
Applicator  for  rectum,  64 
Archer  chair.  62 
Arteries  of  rectum,  16 
Artificial  anus,  closure  of,  55 
Arterial  hseuiorrhoid,  135 
Author's  speculum,  74 

Barker,  closure  of  artificial  anus,  56 
Benign  fungus,  228 

Bistoury  for  external  haemorrhoids,  129 
Bladder,  rectum  ending  in,  42 

relations  of,  to  rectum,  4 
Blind  internal  fistula,  110 
Blood,  defibrinated,  for  rectal  alimentation, 

408 
Bougie,  Laugier's,  72 
Bougies,  70 

danger  of,  73 

rules  for  passing,  72 
Bodenhamer,  classification   of   congenital 
malformations,  37 

colonoscope,  76 
Bread,  laxative,  392 
Brodie,  case  of  reflex  pain,  21 
Brush  for  rectum,  64 
Bushe,  on  valves  of  rectum,  27 
By  id,  cases  of  colotomy,  54 
Byrd's  operation  for  closing  artificial  anus, 
57 

Calculus,  projecting  into  rectum,  4 
Callisen,  operation  of,  49 
Cancer,  320 

age  of  patients,  332 

alveolar,  325 

cases  of  excision,  340 

colloid,  325 

colotomy  for,  360 

diagnosis,  333,  336 

diagnosis  from  benign  polypus,  221 

difficulty  of  distinguishing,  320 

excision,  338 

excision,  after  consequences,  345 

excision,  Cripp's  method,  349 

excision,  history  of,  346 

excision,  Maisonneuve's  method,  348 

excision,  Volkmann's  method,  346 

excision,  when  justifiable,  345 

excision  without  wound  of  sphincter, 
351 

forms  of,  in  rectum,  323 


412 


INDEX. 


Cancer,  general  characteristics,  320 

location,  332 

melanotic,  328 

of  sigmoid  flexure,  excision  of,  352 

osteoid,  329 

palliative  treatment.  359 

partial  excision  of,  361 

rules  for  excision,  343 

symptoms,  333 

treatment,  337 

with  secondary  ulceration  above, '335 
Capillary  haemorrhoids,  134 
Carbolic  acid  for  haemorrhoids,  143 
Case  for  rectal  instruments,  65 
Cauliflower  excrescence,  223 
Caustic  treatment  of  haemorrhoids,  142 
Cauterization  of  prolapse,  164 
Cautery,  Smith's,  154 
Cellulitis,  gangraenous,  100 
Chadwick,  on  third  sphincter,  25 
Chair,  gynaecological,  62 
Chancre,  255 
Chancroids,  252 

Clamp  and  cautery,  Smith's,  154 
Cloquet,  on  valves  of  rectum,  26 
Coccyx,  excision  of,  in  proctotomy,  47 
Cock's-comb,  223 
Colectomy,  352 

conclusions  regarding,  358 

indications  for,  357 

statistics,  357 
Colloid  cancer,  325 
Colon,  guide  to,  in  colotomy,  49 
Colonoscope,  76 
Colotomy,  description  of,  49 

for  cancer,  360 

for  imperforate  anus,  48 

histoi-y  of,  48 

inguinal,  48,  52 

lumbar,  incision  for,  50 

results,  315,  318 

statistics,  317 
Coluinnae  recti,  10 
Concretions,  intestinal,  364 
Condyloma  as  proof  of  syphilitic  ulcera- 
tion. 259 

lata,  228 

vegetating,  228 
Condylomata,  226 

syphilitic,  227 
Congenital  malformations,  36 

tumors,  2-'>'-> 
Congestion  of  rectum,  84 
Constipation,  890 

infantile,  :;'.»! 

treatment,  390 
Cup  for  fusing  nitrate  of  silver,  64 
CurveR  of  rectum,  2 
Cntaneoua  hemorrhoid,  129 
Cysts,  :.':;:; 

DEEP  abscess,  93 
causes  of,  94 
fistula,  110 


Deep  treatment,  123 
Defecation,  physiology  of,  23 
Dermoid  cysts,  233 
Diagnosis,  difficulties  of,  59 
Diaphragm  closing  anus,  37 

of  pelvis,  198 
Dilatation  of  stricture,  293 
Distance  of  peritoneum  from  anus,  7 
Divisions  of  rectum,  3 
Divulsion  of  stricture,  295 
Douglas's  cul-desac,  6 
Dupuytren's  operation,  56 
Dysenteric  stricture,  273 
Dysentery,  251 

Eczema  marginatum,  387 

Elastic  ligature  for  fistula,  116 

Elephantiasis,  249 

Emphysema  of  rectum,  401 

Encephaloid,  325 

Enchondromata,  232 

Enemata  for  rectal  alimentation,  406 

Enterotome  for  fistula,  124 

of  Dupuytren,  56 
Epithelioma,  323 
Erectile  tissues  of  anus,  5 
Ergotine,  injections  for  prolapse,  162 
Erythema,  c89 

Esmarch,  classification  of  congenital  mal- 
formations, 37 
Esthiomene,  249 
Ether,  use  of  for  diagnosis.  61 
Examination,  importance  of,  61 

light  for,  63 

of  rectum,  59 
Excision  of  cancer,  338 

of  coccyx,  47 
External  haemorrhoids,  126 

haemorrhoids,  treatment,  132 

haemorrhoids,  varieties  of,  128 

sphincter,  12 

FAECAL  vomiting,  405 
Faeces,    control   of,    after   destruction   of 
sphincter,  34 

diaguosis  of  impaction,  365 

impacted,  364 
Fascia,  superior  pelvic,  14 
Ferrand,  ergotine  injections  for  prolapse, 

162 
Fibromata,  230 
Fibrous  polypus,  217 
Fissure,  243 

in  children,  267 

incision  of,  266 

symptoms  of,  261 

treatment  of,  264 
Fistula,  107 

and  phthisis,  112 

cauterization  of,  114 

deep,  110  ' 

deep,  treatment,  123 

dressing  after  operation,  122 

horse-shoe,  100 


INDEX. 


418 


Fistula,  internal,  110 

internal  treatment,  123 

knife,  119 

operation  with  gorget,  120 

del  vie,  110 

perineal,  124 

subcutaneous,  109 

submucous,  109 

submuscular,  109 

superficial,  107 

symptoms  of,  109 

track  of,  108 

treatment  by  incision,  118 

treatment  by  ligature,  115 

with  double  tracks,  109 

with  two  internal  openings,  121 
Foetal  inclusions,  236 
Follicles  of  Lieberkuhn,  11 
Forceps  for  haemorrhoids,  149,  151 
Foreign  bodies,  injury  caused  by,  372 

introduced  per  anum,  373 

laparotomy,  380 

prognosis,  378 

swallowed,  369 

treatment,  378 
Foster,  on  physiology  of  rectum,  31 
Fournier,  on  syphiloma,  229 
Fungus,  benign,  228 

Gangrenous  cellulitis,  100 

Gangrene,  260 

Gelatine  suppositories.  82 

Glandular  polypus,  216 

Gonorrhceal  proctitis,  87 

Gorget,  119 

Gosselin,  on  third  sphincter,  29 

Gower,  on  action  of  sphincter,  20 

Gummata,  229 

Gunshot  wounds  of  rectum,  401 

Granular  papilloma,  214 

Green  soap,  formula,  388 

Hemorrhage  from  rectum,  402 

in  operations,  81 
Hasmorrhoid,  arterial,  135 

capillary,  134 

external  cutaneous,  129 

external,  varieties,  128 

venous,  136 
Hasmorrhoidal  forceps,  149,  151 
Hasmorrhoids,  126 

Allingham's  operation  for,  150 

caustic  treatment,  142 

curative  treatment,  141 

external,  inflammation  of,  132 

external,  treatment,  132 

intermediate,  127 

internal,  126 

operation  with  clamp  and  cautery,  153 

palliative  treatment,  138 

reduction  of,  140 

sloughing  of,  137 

Smith's  operation,  153 

symptomatic,  141 


J  Hasmorrhoid*,  symptoms  of,  136 

treatment  by  carbolic  acid,  143 

treatment  by  ligature,  150 

treatment  when  strangulated,  139 

varieties,  126 
Helmuth's  ligature  carrier,  117 

speculum,  74 
Henle,  on  third  sphincter,  24 
Hernia,  internal  rectal.  202 

Kleberg's  operation  for  rectal,  208 

rectal,  182 

rectal,  .anatomy,  198 

rectal,  cases,  184-197 

rectal,  contents,  205 

rectal,  diagnosis,  206 

rectal,  incision  of  the  sac,  211 

rectal,  inflamed,  205 

rectal,  irreducible,  205 

rectal,  sac  of,  200 

rectal,  strangulated,  206 

rectal,  treatment,  207 

rectal,  treatment  after  rupture,  211 
Herpes,  246,  389 
Horse-shoe  abscess,  100 

fistula,  100 

fistula,  operation  for,  121 
Houston,  on  valves  of  rectum,  25 
Houston's  valves,  conclusions  regarding,  35 
Hydratids,  236 
Hyrtl,  on  third  sphincter,  24 

Impacted  fasces,  364 

treatment,  368 
Impaction  of  fasces,  diagnosis  of,  365 
Imperforate  anus,  colotomy  for,  48 

rectum,  39 

operations  in  perinasum,  46 
Inclusions,  foetal,  236 
Incontinence  of  fasces,  operation  for,  105 
Inflamed  external  hasmorrhoids,  131 
Inflammation  of  rectum,  84 
Inflammatory  stricture,  273 
Inguinal  colotomy,  48.  52 
Injecting  apparatus,  66 
Injections  into  hasmorrhoids,  143 

of  iron  in  hasmorrhoids,  148 
Instrument  case,  65 
Intermediate  haemorrhoids,  127 
Internal  fistula,  110 

fistula,  treatment,  123 

hasmorrhoids,  126 

sphincter,  12 
Intestinal  concretions,  364 

obstruction  from  stricture,  280 

treatment,  292 
Intestine,  absence  of,  44 
Intussusception.  170 
Invagination,  170 

causes,  172 

diagnosis,  175 

laparotomy  for,  180 

statistics,  171 

symptoms,  173 

treatment,  176 


414 


INDEX. 


Iron,  treatment  of  haemorrhoids  by  injec- 
tions of,  148 
Irritable  ulcer,  243 
Ischio-coccygeus,  13 

Kidney,  wound  of,  in  .colotorny,  51 
Kleberg's  operation  for  rectal  hernia,  208 
Knife,  for  fistula,  119 
Kohlrausch.  on  valves  of  rectum,  27 

on  valvular  stricture,  274 
Krause,  nerves  of  rectum,  20 

Laparotomy  for  invagination,  180 
Laugier's  bougie  for  measuring  strictures, 

72 
Laxative  bread,  392 
Levator  ani,  13 
coccygis,  13 
Licorice  powder,  139 
Lieberkuhn.  follicles  of,  11 
Ligature  of  haemorrhoids,  150 
Light  for  examinations,  63 
Linear  cauterization  of  prolapse,  164 
Lipomata,  230 
Littre,  operation  of,  48 
Luer's  hemorrhoidal  forceps,  151 
Lund's  colotorny  needles,  51 
Lupus  exedeus,  249 
Lymphatics  of  rectum,  22 

Malformations  of  rectum  and  anus,  36 

treatment  of,  44 

use  of  trocar,  45 
Malignant  adenoma,  320 
Manual  exploration,  78 
Measurements  of  rectum,  78 
Melanotic  cancer,  328 
Mitchell's  suppositories,  82 
Molliere,  classification  of  congenital  mal- 
formation, 37 
Mucous  membrane  of  rectum,  9 
Muscularis  mucosae,  10 
Muscles  of  anus.  11 

of  rectum,  11 

N^kvus  of  rectum,  402 

Narrowing   of   rectum   or    anus    without 

complete  occlusion.  37 
Nelaton,  on  third  sphincter,  23 
Nerves  of  rectum,  19 
Neuralgia  of  the  rectum,  398 
Nitric  acid  applications  for  prolapse,  163 

for  ulceration,  270 
Non-malignant  stricture,  271 
excision.  :!1  I 
ulceration,  241 
Non-venereal  stricture,  273 
Xussbaum's  cases  of  excision  of  the  rec- 
tum, 851 

O'Beirne,  on  defecation.  2  i,  30 
Occlusion  of  rectum  or  anus,  37 
Operating  chair,  62 

Operation  for  incontinence  of  fasces,  106 
in  congenital  malformations,  44 


Operation  of  Amussat,  47 

of  Callisen,  49 

of  Littre,  48 
Operations,  after-treatment,  82 
Osteoid  cancer,  329 
Owen,  cases  of  imperforate  anus,  53 

Paget,  on  syphilitic  ulceration,  257 
Pain,  reflex,  in  rectal  disease,  21 
Papendorf,     classification     of     congenital 

malformations,  37 
Papilloma,  granular,  214 
Papillomata,  221 
Paquelin's  thermocautery,  80 
Parturition,  as  cause  of  ulceration,  242 
Pathological  anatomy  of  stricture,  277 
Pederasty,  6 
Pelvic  abscess,  97 

diaphragm,  198 

fascia,  14 

fistula,  110 
Pelvirectal  space,  15 

description  of,  93 
Perineal  fistula,  124 
Peristalsis,  reverse,  404 
Peritoneum,  distance  of,  from  anus,  7 

relations  of,  to  rectum,  6 
Peritonitis  caused  by  stricture,  279 
Petrequin,  on  third  sphincter,  24 
Phthisis  and  fistula.  112 
Pilo-nidal  sinus,  235 
Polyadenomata,  217 
Polypus,  213 

adenomatous,  216 

benign,  distinguished  from  cancer,  221 

connected  with  fissure,  246 

containing  peritoneum,  219 

diagnosis,  220 

fibrous,  217 

glandular,  216 

hard,  213 

sarcomatous,  217 

soft,  213 

symptoms,  219 

treatment,  221 

villous,  214 
Position  for  examination,  64 
Posterior  umbilicus,  235 
Proctitis,  84 

acute,  86 

causes,  87 

chronic,  87 

gonorrhoeal,  87 

localized,  86 

symptoms  of,  86 

treatment,  88 
Proctoplasty,  47 
Proctotomy,  external,  299 

internal,  298 

knife,  301 

literature  of,  314 
Prolapse,  156 

causes,  158 

cauterization,  103 


INDEX. 


415 


Prolapse,  changes  in  coats  of,  167 

extirpation  of,  168 

first  variety,  157 

of  mucous  membrane  only,  158 

of  second  degree,  1 66 

operation  for,  161 

operation  with  elastic  ligature,  169 

operation  with  Smith's  clamp,  165 

reduction  of  inflamed,  168 

second  variety,  157 

strangulation,  167 

symptoms,  159 

third  and  fourth  varieties,  157,  169 

treatment,  160 

treatment  by  injections,  163 

varieties,  156 

with  circular  slough,  168 

with  rectal  hernia,  201 
Prostate,  relations  of,  to  rectum,  4 
Pruritus  ani,  385 

causes,  886 

changes  in  the  skin,  386 

prognosis,  394 

treatment,  387 
Purgatives  causing  proctitis,  87 
Pus  basin,  67 

Rectal  absorption,  403 

alimentation,  403 

alimentation,  rules  for  applying,  409 

bougies,  70 

depressor,  76 

digestion,  403 

enemata,  406 

hernia,  182 

hernia,  anatomy,  198 

hernia,  cases,  184-197 

hernia,  contents,  205 

hernia,  diagnosis,  206 

hernia,  incision  of  the  sac,  211 

hernia,  inflamed,  205 

hernia,  internal,  202 

hernia,  irreducible,  205 

hernia,  Kleberg's  operation,  208 

hernia,  sac  of,  200 

hernia,  strangulated,  206 

hernia,  treatment,  207 

hernia,  treatment  after  rupture,  211 

hernia,  varieties,  182 

supporter,  161 

touch,  68 

valves,  conclusions  regarding,  35 
Recto-coccygeus,  12 
Rectum,  absence  of,  43 

anatomy  of  muscular  coat,  8 

arteries  of,  16 

circular  muscular  fibres,  8 

congestion  of,  84 

curves  of,  2 

development  of,  in  embryo,  36 

divided  into  four  sacs,  40 

divisions  of,  3 

emphysema  of,  401 

ending  in  bladder,  42 


Rectum,  ending  in  blind  pouch,  38 

ending  in  fistulous  track;  40 

ending  in  urethra,  43 

examination  of,  59 

excision  of,  different  methods  of,  346 

glands  of ,  11 

gunshot  wounds  of,  401 

haemorrhage  from,  402 

haemorrhage  in  operations,  81 

imperforate,  anus  normal,  39 

imperforate,  operations  in  perinaeum, 
46 

inflammation  of,  84 

injection  of,  for  exploration,  72 

injury  in  childbirth,  400 

length  of,  1 

longitudinal  muscular  fibres,  8 

lymphatics  of,  22 

malformations  of,  36 

manual  exploration,  78 

mucous  membrane  of,  9 

muscles  of,  11 

naevus  of,  402 

nerves  of,  19 

neuralgia,  398 

Nussbaum's  cases  of  excision,  351 

opening  in  perineum,  40 

opening  in  sacral  region,  40 

packing  of,  82 

position  of,  1 

relations  of,  4 

rules  for  operations,  79 

rupture  of,  203 

submucous  coat  of,  9 

upper  limit  of,  2 

valves  of,  25 

veins  of,  16 

Weir's  measurements,  78 

wounds  of,  400 
Relations  of  rectum,  4 
Residual  abscess,  95 
Retention  of  urine  after  operations,  83 
Retractor  recti,  12 
Reverse  peristalsis,  404 
Richet,  superior  pelvi-rectal  space,  15 
Rodent  ulcer,  251 
Rupture  of  rectum,  203 

Sac  of  rectal  hernia.  200 

Sappey,  on  third  sphincter,  24 

Sarcomatous  polypus,  217 

Scirrhus,  324 

Sclerosis,  syphilitic,  276 

Scrofula.  249 

Secondary  syphilis,  256 

Septa  in  rectum,  40 

Sigmoid  flexure,  malposition  of,  3,  52 

Sinus  of  Morgagni,  inflammation  of,  244 

pilo-nidal,  235 
Smith's  clamp  and  cautery.  154 

ovjeration  compared  with  Allingham's, 
155 

operation  for  haemorrhoids,  154 
Sodomy  as  a  cause  of  ulceration,  242 


416 


IXDEX. 


Space,  superior  pelvi-rectal,  15 
Spasm  of  sphincter.  395 
Spasmodic  stricture,  272 
Spina  bifida,  238 
Specula?,  use  of,  73 
Speculum,  author's,  74 

Helmuth's,  74 
Sphincter,  external,  12 

external,  nerve  control  of,  20 

forcible  stretching-,  266 

internal.  12 

spasm  of,  395 

stretching  of,  77 

third,  23 

third,  conclusions  regarding,  35 
Sponge-holder,  64 
Stethoscope,  used  over  anus,  39 
Stricture,  acquired,  272 

cause  of  abscess,  279 

cause  of  obstruction,  282 

cause  of  peritonitis,  279 

cause  of  ulceration,  260 

cicatricial  venereal.  276 

congenital  of  rectum  or  anus,  37 

diagnosis,  73,  78,  283 

division  of,  298 

dysenteric,  273 

examination  for,  68,  285 

from  hypertrophy  of  rectal  valves,  274 

general  treatment,  286 

how  to  measure  length  of,  72 

inflammatory,  273 

neoplastic  venereal,  276 

non-malignant,  271 

non-malignant,  treatment  when  high 
up,  318 

non-venereal,  273 

pathological  anatomy,  277 

secondary  effects,  279 

shape  of  fasces,  280 

spasmodic,  272 

symptoms,  280 

treatment  by  dilatation,  293 

treatment  by  divulsion,  295 

traumatic.  275 

varieties  of,  271 
Subcutaneous  fistula,  109 
Submucous  fistula,  109 
Submuscular  fistula,  109 
Superior  pelvi-rectal  space,  15,  93 
Suppositories,  Mitchell's,  82 

nutritive,  409 
Suskenator  tunicas  mucosas,  10 
Syphilis,  secondary,  2J6 

tertiary.  256 
Syphilitic  sclerosis,  276 

ulceration  of  colon,  258 
Syphiloma,  ano-rectal,  229,  260 

Talma,  case  of,  278 
Taxis  for  haemorrhoids,  140 
Tensor  fasciae  pelvis,  12 
Tertiary  syphilis,  256 
Thermo-cautery,  W 


Third  sphincter,  23 

conclusions  regarding,  35 
Transversus  perinei,  15 
Traumatic  stricture,  275 
Trocar,  use  of,  in  malformations,  45 
Tubercular  ulcer,  246 

ulceration  of  colon,  257 
Tumor,  peculiar  bleeding,  214 

villous,  214 
Tumors,  congenital,  233 

Ulcer,  irritable,  243 

rodent,  251 

simple,  241 

tubercular.  246 

venereal,  252 
Ulceration,  caused  by  parturition,  242 

caused  by  sodomy,  242 

caused  by  stricture,  260 

characters  of  syphilitic,  257 

diagnosis  of,  263 

diagnosis  of  syphilitic  from  tubercular, 
257 

division  of  sphincter  for,  269 

follicular,  86 

non-malignant,  241 

symptoms  of,  262 

syphilitic  of  colon,  258 

treated  bv  nitric  acid,  270 

treatment  of,  264,  267 

tubercular  of  colon,  257 
Umbilicus,  posterior,  235 
Ureters  emptying  in  rectum,  43 
Urethra,  rectum  ending  in,  43 

relation  of,  to  rectum,  4 
Urine,  retention  after  operations,  83 
Uterus,  emptying  in  rectum,  43 

Vagina  ending  in  rectum,  43 
Valves  of  rectum,  25 

conclusions  regarding.  35 
Van  Buren,  on  imperforate  rectum,  46 
Vegetating  condyloma,  228 
Vegetations,  221 

diagnosis,  225 

non -syphilitic.  223 

symptoms,  224 

treatment,  226 
Veins  of  rectum,  16 
Velpeau,  on  third  sphincter,  24 
Venereal  cicatricial  stricture,  276 

neoplastic  stricture,  276 

stricture,  treatment,  287 

ulcers,  252 
Venous  hasmorrhoid,  136 
Vidal,    ergotine   injections    for    prolapse, 

162 
Vienna  paste  for  haemorrhoids,  143 
Villous  polypus,  214 
Vomiting  of  faeces,  405 

Warts,  221 

Weir's  measurements  of  rectum,  78 
Wounds  of  rectum,  40J 


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student  of  pathology,  and  should  be  in  every 
physician's  library." — Philadelphia  Medical 
Times. 

"It  is  a  book  full  of  knowledge  for  the 
practitioner.  A  medical  student  could  not 
better  commence  work  than  by  reading  this 
book  through.  It  has  all  the  modern  doctrines 
and  discoveries." — The  Clinic. 

"The  views  now  held  by  progressive  inves- 
tigators in  this  branch  of  medical  science  are 
given  in  a  marvellous  mass  of  well-arranged 
and  carefully  digested  facts,  embracing  all  de- 
partments of  pathology,  and  furnishing  minute 
and  detailed  information  on  every  subject  per- 
taining to  the  morbid  state  and  disease  in  all 
its  protean  forms.  Wagner's  systematic  ar- 
rangement and  skill  in  classification  are  ad- 
mirable, particularly  elucidating  the  bearings 
of  facts  upon  the  processes  of  disease." — 
American  Journal  of  the  Medical  Sciences. 

"  Messrs.  Wm.  Wood  &  Co.  have  placed  the 
profession  of  this  country  under  renewed  obli- 
gations by  the  presentation  of  this  inimitable 
work.  The  most  popular  text-book  in  Ger- 
many, and  having  passed  through  six  editions 
in  that  country,  the  only  wonder  is  that  it  has 
not  been  given  to  the  profession  of  America 
before  this.  The  most  cursory  glance  through 
it  is  sufficient  to  convince  cue  of  the  excellence 
of  the  work,  which  bears  the  imprint  of  one  of 


the  greatest  German  minds.  The  bibliography 
of  the  work  before  us  is  very  replete,  and  evinces 
a  research  rarely  entered  into  by  authors.  The 
work  consists  of  four  parts,  devoted  respec- 
tively to  General  Nosology,  General  Etiology, 
General  Pathology,  Anatomy  and  Physiology, 
and  Pathology  of  the  Blood." — Peninsular 
Journal  of  Medicine. 

"  The  work  is  one  which  will  amply  repay 
perusal ;  in  fact,  no  physician  should  neglect 
to  read  it,  and  the  student  should  make  it  one 
of  his  most  cherished  text-books." — Buffalo 
Medical  and  Siirgical  Journal. 

"Clear  and  concise  statements,  short  and 
simple  sentences,  present  the  condensed 
thought  with  which  this  volume  is  filled. 
This  is  as  it  should  be.  Those  who  desire 
more  than  carefully  arranged  results  will  find 
in  the  copious  bibliography  and  abundant  in- 
tercalated references  the  sources  from  which 
the  information  has  been  derived.  An  index 
of  authors  and  another  of  subjects  render  in- 
valuable aid.  We  consider  this  book  as  one 
of  the  most  valuable  of  the  many  medical 
works  translated  from  German  into  English. 
Its  application  is  general,  for  it  will  be  found 
not  only  upon  the  shelves  of  the  surgeon  and 
physician,  but  also  in  the  hands  of  the  medical 
student,  who  can  rely  upon  no  safer  and  surer 
guide  through  the  obscurity  which  surrounds 
the  causes  and  phenomena  of  disease.  The 
modern  explanation  of  'catching  cold  '  may  be 
seen,  as  well  as  the  more  elaborate  theories 
with  regard  to  fever.  Above  all,  it  contains 
what  is  to  be  found  in  no  other  single  volume 
— it  is  filled  with  a  complete  and  compre- 
hensive series  of  systematically  arranged  ab- 
stracts, which  form  an  epitome  of  general  pa- 
thology." —  Boston  Medical  and  Surgical 
Journal. 


Longstreth,  Morris,  M.D.,  etc. 


RHEUMATISM,  GOUT,  AND  SOME  OF  THE  ALLIED  DISEASES. 

I.     subscription.     See  page  54. 


Sold   enly 


Barwell,  Richard,  F.R.C.S , 

Surgeon  Charing-Cross  Hospital,  etc. 

A  TPEATISE  ON  DISEASES  OF  THE  JOINTS, 
gravings  on  wood.      Sold  only  by  subscription. 

Lyman,  Henry  M.,  A.M.,  M.D., 


Illustrated   by   numerous   en- 
See  page  55. 


•or  of  Physiology  and  Nervous  Diseases  in  Rush  Medical  College,  and  Professor  of  Theory  and 
P  •"  bice  of,  Medicine  In  the  Women's  Medical  College,  Chicago,  111. 

ARTIFICIAL  ANAESTHESIA  AND   ANAESTHETICS.     Sold  only  by  subscription. 
See  page  55. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


Diseases  of  Old  Age,  Electricity. 


Index  Rerum 

For  the  Use  of  Physicians  and  others.      Sold  only  hy  subscription.     See  page  64. 

Charcot,  J.  M.,  M.D., 

Brofessor  in  Faculty  of  Medicine  of  Paris ;  Physician  to  the  Salpetriere  :  Member  of  the  Academy  of 
Medicine;  of  the  Clinical  Society  of  London  :  of  the  Clinical  Society  of  Buda-Pesth  ;  of  the  Society 
of  Natural  Sciences,  Brussels  ;  President  of  the  Anatomical  Society,  etc.,  etc. 

THE  DISEASES  OF  OLD  AGE.  Translated  hy  L.  Harrison  Hunt,  M.D.,  with 
numerous  additions  by  A.  L.  Loomis,  M.D.,  etc.,  Professor  of  Pathology  and 
Practical  Medicine  in  the  Medical  Department  of  the  University  of  the  City  of 
New  York  ;  Consulting  Physician  in  the  Charity  Hospital ;  to  the  Bureau  of 
Out-Door  Relief  ;  to  the  Central  Dispensary  ;  Visiting  Physician  to  the  Bellevne 
Hospital  ;  to  the  Mount  Sinai  Hospital,  etc.,  etc.  Sold  only  by  subscription. 
See  page  55. 


Beard,  Geo.  M ,  A.M.,  M.D., 


Fellow  of  the  New  York  Academy  of  Medicine  ;  Member  of  the  American  Academy  of  Medicine  ;  Mem- 
ber of  the  American  Neurological  Association,  of  the  New  York  Neurological  Society,  etc.  ;  and 


Rockwell,  A.  D.,  A.M.,  M.D., 


Fellow  of  the  New  York  Academy  of  Medicine  ;  Member  of  the  American  Academy  of  Medicine  ;  Mem- 
ber of  the  American  Neurological  Association ;  Electro-therapeutist  to  the  Woman's  Hospital  of  the 
State  of  New  York,  etc. 

k  PRACTICAL  TREATISE  ON  THE  MEDICAL  AND  SURGICAL  USES  OF 
ELECTRICITY,  INCLUDING  LOCALIZED  AND  GENERAL  FARADIZA- 
TION ;  LOCALIZED  AND  CENTRAL  GALVANIZATION  ;  ELECTROLYSIS 
AND  GALVANO-CAUTERY.     Fourth  Edition.     Revised  by  A.  D.  Rockwell, 

M  D.     One  volume,  8vo,  788  pages,  one  hundred  and  eighty-nine  wood-engrav- 
ings.    Price,  muslin,  $5.50  ;  leather,  $6.50. 


"  The  impression  it  gives  at  first  sight  is 
very  favorable ;  it  is  beautifully  printed,  and 
illustrated  with  wood  cuts  in  a  way  which  can- 
not fail  to  be  most  useful  to  students. 

"The  matter  of  the  volume,  again,  is  ad- 
mirably arranged  ;  better  than  in  any  book  of 
the  kind  which  I  have  seen. 

"References  are  numerous  and  accurate, 
and  we  are  delighted  to  have  that  which  we 
lack  so  much  in  almost  all  other  such  books, 
namely,  complete  indexes,  both  verbal  and 
bibliographical.  They  have  perfected,  if  they 
did  not  originate,  a  method  of  electro-thera- 
py which  they  call  general. faradization. 

"It  is  a  pleasing  featxre  in  the  present  vol- 
ume that  the  unsuccessful  cases  bear  their  just 
proportion  to  the  successful,  and  that  in  other 
instances  where  success  was  incomplete  there 
is  no  attempt  to  make  the  results  more  satis- 
factory than  they  really  were." — British  and 
Foreign  Medico-Chirurgical  Review. 

"We  can  really  congratulate  Drs.  Beard 
and  Rockwell  on  the  production  of  a  very  ex- 
haustive work,  thoroughly  up  to  the  times, 
and  evincing  an  intimate  familiarity  with  the 
subject,  a  cordial  recognition  of  the  labors  of 
home  and  foreign  writers,  and  a  laudable  de- 
sire to  give  an  honest  account  of  their  cases, 
not  magnifying  their  successes  nor  conceal- 
ing their  failures.  " — Dublin  Quarterly  Jour- 
nal. 

' '  Supplies  a  long-existing  want  in  electro- 
therapeutics. 

"  We  know  of  no  other  work  on  the  subject 
that  gives  anything  like  the  practical  instruc- 


tion that  we  find  h  re." — Michigan  University 
Medical  Journal. 

"More  important  assistance  perhaps  is  giv- 
en by  the  illustrations  to  the  chapters,  or  the 
modus  operandi,  where  the  various  methods 
of  applying  the  apparatus  in  the  treatment  of 
the  different  affections  is  explained." — London 
Journal  of  Mental  Science. 

"  It  is  unquestionably  the  best  and  simplest 
authority  on  this  subject  at  present  accessible. 
Those  who  want  in  this  connection  to  be 
abreast  of  the  times  can  purchase  a  work 
which  will  be  most  satisfactory  and  reliable. " 
— Richmond  Medical  Journal. 

"The  complicated  methods  and  nomencla- 
tures that  have  disheartened  the  puzzled  works 
of  previous  authors  on  this  branch  of  medicine, 
have  been  pruned  of  redundancies  and  con- 
founding synonyms." — American  Practition- 
er. 

"In  the  arrangement  of  their  material,  in 
the  presentation  of  their  subject-matter,  in 
the  scope  of  their  studies,  in  the  manly 
though  modest  manner  in  which  they  press 
their  own  views,  and  in  the  very  attractive 
manner  in  which  the  volume  is  published, 
Drs.  Beard  and  Rockwell  must  b  -  compli- 
mented as  having  produced  a  very  readable 
and  instructive  work  on  medical  electricity, 
and  one  which  will,  perhaps,  answer  the  re- 
quirements of  the  busy  practitioner  better 
than  any  single  work  on  the  subject  which  has 
appeared  in  original  English,  or  been  trans- 
lated from  a  foreign  language." — New  York 
Medical  Record. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 
Electricity,  Massage. 


Rockwell,  A.  D.,  A.M.,  M.D., 


rapeutist  to  the  New  York  State  Woman's  Ho-pital :  Member  of  the  American  Neurologi- 
cal Aswjciation  ;  Fellow  o£  the  New  York  Academy  of  Medicine ;  Member  of  the  New  York  County 
Medical  Society,  eta 

LECTUBES  OX  ELECTRICITY  (DYNAMIC  AND  FRAXKLLXIC)  IX  ITS  RE- 
LATIONS TO  MEDICINE  AXD  SURGERY.  One  volume,  8vo,  122  pages, 
illustrated,  muslin.     Price.  $1.25. 


' '  C  >ntains  all  that  is  practical  and  useful  on 

-  .'oject  to  the  practitioner ;  it  is  concise 

and  interesting  to  read,  and  should  be  in  the 

hands  of  every  practitioner. " —  Western  L»  n  eet. 

'•  Practitioners  wishing  to  obtain  a  knowl- 
edge of  the  methods  of  applying  and  indica- 
tion- for  using  electricity  in  the  treatment  of 
disease,  cannot  find  more  useful  information 
in  a  small  compass  than  is  contained  in  these 
lectures.  We  take  pleasure  in  commending  it 
to  their  notice." — Canada  Journal  of  Medical 
St  it  nces. 


"These  lectures  embrace  the  more  impor- 
tant practical  matters,  as  the  manipulations  of 
apparatus,  and  the  fields  of  disease  where  elec- 
tricity will  promise  the  most  good  " — Obstetric 
Gazette. 

'  •  At  the  close  of  the  book  there  are  a  series 
of  pithy  paragraphs,  giving,  in  plain  language, 
the  practical  applications  of  the  different  cur- 
rents to  various  affections,  as  shown  by  the 
personal  experience  of  the  writer,  and  those  of 
other  competent  specialists.-' — Medical  Rec- 
ord. 


Graham,  Douglas,  M.D., 

Fellow  of  the  Massachusetts  Medical  Society. 

A  PRACTICAL  TREATISE  OX  MASSAGE.  Its  History,  Mode  of  Application,  and 
Effects,  Indication  and  Contra-indication.  One  handsome  volume,  8vo,  300 
pages.     Price,  in  cloth,  $2.50. 


"We  commend  the  work  to  those  who  are 
investigating  the  merits  of  friction,  kneading, 
manipulating,  rolling,  and  percussion  of-  the 
external  tissues  of  the  body,  with  a  view  to 
their  curative,  palliative,  or  hygienic  effects.'' 
— Buffalo  Medical  and  Surgical  Journal. 

"  Coming  from  the  hands  of  a  medical 
man  of  reputation,  the  work  may  be  accepted 
as  an  authority  in  explaining  this  resuscita- 
ted science,  and  as  a  guide  to  its  practice." 
— Boston  Evening  Transcript.  December  31, 
1884. 

1 '  A  complete  history,  from  the  beginning 


until  now,  will  be  found  in  Dr.  Graham's  ex- 
cellent volume." — .Baltimore  <b'w«,  December 
11.  1881 

•l  The  subject  of  massage  has  been  one 
toward  which  the  attention  of  the  profession 
has  been  directed  more  and  more  of  late  years. 
As  a  therapeutic  measure,  it  has  been  growing 
steadilv  in  favor." — Medical  and  Surgical  /.'«- 
porter,  October  20.  1884. 

■lThis  is  a  valnable  professional  book  for 
which,  and  for  the  subject  to  which  it  is  de- 
we  venture  to  predict  distinguished 
success." — Thi  Nation,  January  1,  1885. 


Morgan,  Chas.  E.,  A.B.,  M.D. 


ELECTRO-PHYSIOLOGY  AXD  THERAPEUTICS  :  BEIXG  A  STUDY  OE  THE 
ELECTRICAL  AXD  OTHER  PHYSICAL  PHENOMENA  OF  THE  MUSCU- 
LAR  AXD  OTHER  SYSTEMS  DURIXG  HEALTH  AND  DISEASE,  IXCLUD- 
IXG  THE  PHENOMENA  OF  THE  FLEr'TRICAL  FISHES.  One  volume,  8vo, 
714  pages,  illustrated  with  fine  wood-engravings,  muslin.     Price,  $6.50. 

"This  book  is  a  mine  of  knowledge  to  the  ''There  is  nothing  in  the  English  language 

stud  i.t  in  the  department  of  science  to  which  which  at  all  approaches  it  as  regards  the  scien- 

s.     .     .    .     It  is  a  most  thorough  and  tific  treatment  of  the  whole  subject  of  electri- 

oompp-hensive    treatise    on    the    subject." —  city." — Detroit  lievicw  of  Medicine  and  Ph*r- 

Wextern  Journal  of  Medicine.  macy. 


Erb,  Dr.  Wilhelm, 

Professor  in  the  University  of  Leipzig. 

HAXDP,OOK  OF  ELECTRO-THERAPEUTICS.     Illustrated  by  39  wood-engravings. 
only  by  subscription.     See  page  53. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Fevers,  Diseases  of  the  Liver. 


Seguin,  E.,  M.D. 

MEDICAL    THERMOMETRY    AND    HUMAN    TEMPERATURE. 

8vo,  445  pages,  illustrated  with,  diagrams,  mnslin.     Price,  $3.50. 


One   volume, 


"The  subject-matter  of  this  volume  is  of  i 
the  highest  importance,  and  the  profession  is 
under  great  obligations  to  its  author  for  the 
zeal  he  has  manifested  in  bringing  it  to  our  no-  ; 
tice.  The  book  is  worthy  of  careful  study  by  i 
every  medical  student  and  studious  practi-  ! 
tioner. " — Detroit  Review  of  Medicine  and  Stir-  I 

"  This  elaborate,  elegantly  printed,  and  il- 
lustrated work  contains  a  full  description  of 
everything  pertaining  to  thermometry — the 
character  of  the  instruments,  their  value,  uses,  j 
etc.  Numerous  tables  are  given  from  various 
American  and  foreign   authors   and  writers, 


exhibiting  the  temperature  in  various  diseases. 
Among  these  are  Dr.  Joseph  Jones'  in  '  Yel- 
low Fever,'  where  the  temperature  is  cited  in 
two  cases  which  terminated  fatally  at  110°. 
The  illustrations,  temperature  charts,  etc., 
are  eighty-four  in  number,  and  are  very  hand- 
somely executed.  We  cordially  commend  the 
work  to  our  rt  aders  as  a  highly  valuable  con- 
tribution to  the  study  and  cultivation  of  the 
most  important  aid  to  diagnosis  (after  auscul- 
tation and  percussion),  now  specially  claim- 
ing and  rewarding  the  attention  of  physi- 
cians."—  Charleston  Medical  Journal  and 
Review. 


Gregory,  G-eorge,  M.D., 


Fellow  of  the  Royal  College  of  Physicians  of  London  :  Physician  to  the  Small-pox  and  Vaccination  Hos- 
pital at  Highgate  ;  Corresponding  Member  of  the  National  Institute  of  Washington,  etc. 

LECTURES  ON  THE  ERUPTIVE  FEVERS  :  As  now  in  tlie  Course  of  Delivery  at 
St.  Thomas'  Hospital,  in  London.  With  Notes  and  Appendix,  embodying  the 
most  recent  opinions  on  exantliematic  pathology,  and  also  statistical  tables  and 
colored  plates,  by  H.  D.  Bulkley,  M.D.,  Physician  of  the  New  York  Hospital; 
Fellow  of  the  New  York  College  of  Physicians  and  Surgeons,  etc.,  etc.  One 
volume,  8vo,  379  pages,  muslin.     Price,  $8.00. 

"The  very  best  which  has  yet  been  pub- |  "This  work  abounds  with  valuable  infor- 
lished  on  Eruptive  Fevers  ;  and  one  which  |  mation  in  regard  to  a  class  of  diseases  of  very 
it  should  be  the  duty  of  every  physician  to  j  frequent  occurrence  and  of  fearful  mortality." 
provide  himself  with." — Northern  Lancet.         I  — Stethoscope. 


Wilson,  James  C,  M.D., 


attending  Physician  to  the  Philadelphia  Hospital,  and  to  the  Hospital  of  the  Jefferson  Medical  College> 
and  Lecturer  on  Physical  Diagnosis  at  the  Jefferson  Medical  College,  Fellow  of  the  College  of  Phy- 
sicians, Philadelphia,  etc. 

k  TREATISE  ON  THE  CONTINUED  FEVERS.  With  an  Introduction  by  J.  M. 
Da  Costa,  M.D.,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine 
at  the  Jefferson  Medical  College  ;  Physician  to  the  Pennsylvania  Hospital  ;  Con- 
sulting Physician  to  the  Children's  Hospital ;  Fellow  of  the  College  of  Physicians, 
Philadelphia,  etc.     Sold  only  by  subscription.     See  page  55. 


Murchison,  Charles,  M.D,,  LL.D.,  F.R.S., 


Fellow  of  the  Royal  College  of  rhysicians  ;  President  of  the  Pathological  Society  of  London  ;  Physician 
and  Lecturer  on  the  Principles  and  Practice  of  Medicine,  St.  Thomas'  Hospital,  etc. 

CLINICAL  LECTURES  ON  DISEASES  OF  THE  LIVER.  JAUNDICE  AND 
ABDOMINAL  DROPSY.  Including  the  Croonian  Lectures  on  Functional  De- 
rangements of  the  Liver,  delivered  at  the  Royal  College  of  Physicians.  New 
edition  preparing. 


"  A  book  which  surpasses  in  clinical  useful- 
ness every  work  on  diseases  of  the  liver  yet 
published." — Medico- Chirurgical  Revievi. 

"  It  is  the  most  instructive,  the  most  teach- 
ing, work  on  its  subject  in  our  language. " — St. 
Louis  Medical  and  Surgical  Journal. 

"  A  monograph  on  '  Liver  Affections,'  which 
may  be  profitably  read  by  the  student ;  and  in 
which  the  physician  will  find  a  system  of  diag- 
nosis  both   practical   in  its   application    and 


thoroughly  scientific  in  the  principles  on  which 
it  is  based.  .  .  .  We  commend  Dr.  Mur- 
chison's  volume  in  the  highest  terms  of  praise 
to  the  notice  of  our  readers.  It  is  a  book  full 
of  facts,  clearly  and  forcibly  written  ;  and  em- 
bodying the  latest  results  of  scientific  and 
clinical  research.  It  must  henceforth  occupy 
a  high  rank  among  works  of  reference  on  the 
diagnosis  and  treatment  of  affections  of  the 
liver." — The  Practitioner. 


8         PUBLICATIONS  OF  ^HLLIAM  WOOD  &  COMPANY. 
Diseases  of  the  Liver,  Practice  of  Medicine. 
Murchison,  Charles,  M  D.,  LL.D.,  F.R.S., 

Fellow  of  the  Royal  College  of  Physicians  ;  Physician  and  Lecturer  on  the  Principles  and  Practice  of 
Medicine,  St.  Thomas'  Hospital ;  Vice-President  and  Consulting  Physician,  London  Fever  Hos- 
pital, etc. 

OX  FUNCTIONAL  DERANGEMENTS  OF  THE  LIVER:  Being  the  Crooniau  Lect- 
ures delivered  at  the  Royal  College  of  Physicians  in  March,  1874.  One  volume, 
12rao,  182  pages,  illustrated,  muslin.     Price,  $1.75. 

"This  monograph  is  an  excellent  contribu-  given  in  this  little  book,   the  reprint  of  the 

ton  to  medical  literature,  and  is  worthy  of  a  Croonian  lectures,  a  clear  and  comprehensive 

place  in  every  medical  library." — Cincinnati  summary   of    the    present    state    of    medical 

Lancet  and  Observer.  knowledge  concerning  the   relation  of    func- 

"  There  is  not  a   physician   anywhere  who  tional  hepatic  disorders  to   the   various  vital 

will  not  read  with  avidity  and  profit  this  ad-  processes." — Boston    Medical    and    Surgical 

mirable  exposition  of  this  classic  and  most  im-  Journal. 
portant  subject." — American  Medical  Weekly.        "This   admirable  volume,    the   work  of  a 

"  This  work  does  not  need  special  criticism  practitioner  who  has  brought  to  the  investiga- 

at  our  hands,  for  its  author  is  known  to  be  a  tion  of  this  subject  all  the  light  of  modern 

distinguished  master  of  the  subject  on  which  physiological  science  will  exert  a  decided  in- 

he  has'  discoursed.     His  name  has  long  been  fluence  on  the  minds   of  medical  men,   and 

identified  with  careful  original  researches  in  awaken  renewed  interest  in  the  complaints  of 

this   department    of  pathology,    and    he  has  which  it  treats." — The  American  Practitioner : 

Frerichs,  Dr.  Fried.  Theod. 

A  CLINICAL  TREATISE  ON  DISEASES  OF  THE  LITER.  Translated  by 
Charles  Murchison,  M.D.  In  three  volumes,  8vo.  Illustrated  by  a  full- 
paee  plate  and  numerous  wood-engravings.  Sold  only  by  subscription.  See 
page  57. 

Bristowe,  John  Syer,  M.D., 

And  others. 
DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.  Comprising  Articles  on— 
Enteralgia,  by  John  Richard  Wardell,  M.D.  ;  Enteritis,  Obstruction  of  the 
Bowels,  Ulceration  of  the  Bowels,  Cancerous  and  other  Growths  of  the  Intes- 
tines, Diseases  of  the  Cfecum  and  Appendix  Vermiformis,  by  Johx  Syer  Bris- 
towe, M.D.  ;  Colic,  Colitis,  and  Dysentery,  by  J.  Warburton  Begbie,  M.D.  ; 
Diseases  of  the  Rectum  and  Anus*  by  Thomas  Blizzard  Curling-,  F.R.S.  ; 
Intestinal  Worms,  by  W.  H.  Ransom,  M.D.  ;  Peritonitis,  by  John  Richard 
Wardell,  M.D.  ;  Tubercle  of  the  Peritoneum,  Carcinoma  of  the  Peritoneum, 
Affections  of  the  Abdominal  Lymphatic  Glands,  and  Ascites,  by  John  Syer 
Bristowe,  M.D.     Sold  only  by  subscription.     See  page  57. 

Bennett,  John  Hughes,  M.D.,  F.H.S.E., 

Professor  of  the  Institutes  of  Medicine,  and  Sen'or  Professor  of  Clinical  Medicine  in  the  University  of 
Edinburgh  ;  Director  of  the  Polyclinic  at  the  Royal  Dispensary  and  Pathologist  to  the   Royal   In- 
firmary, Edinburgh  ;  Honorary  Member  and  Emeritus  President  of  the  Royal  Medical  Society  of 
Edinburgh,  etc. 
CLINICAL  LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE  OF  MEDICINE. 
Fifth   American  from   the  Fourth  London  Edition,     With   five  hundred  and 
thirtv-seven  illustrations  on  wood.     One  volume,  8vo,  1022  pages.     Price,  mus- 
lin, $5.00;  leather,  $6.00. 
"  We  recommend  this  volume  with  the  most    which  have  come  over  the  practice  of  medi- 
ur.qualified  praise  to  the  attentive   consider-    cine ;  and   for  this,  more  than   for  anything 
ation  of  the  practitioner  and  students.     We    else,  we  value  him  and  the  books  which  record 
have  met  with  no  work  of  late  years  on  the    his  news  and  cases.     .     .     .     This  is  a  most 
principles  of  medicine  more  likely  to  advance    valuable  book,  and  records  work  and  original 
the  true  and  rightful  study  of  our  art." — Med-    views  which  will  secure  for  the  author  a  last- 
ed Times  and  Gazette.  ing  and  enviable  reputation  as  a  physiologist 

'•When  a  book— especially  so  large  a  book    and  physician."— London  Lancet. 
as  this— reaches  a  fourth  edition,   it  may  be        "  One  of  the   most   valuable  books  which 
considered   to  be  pretty  independent  of  re-    have  lately  emanated  from  the  medical  press, 
views  and  reviewers.  '  No  one  devoted  to  the  profession  will  fail  to 

"  It  would  be  scarcely  too  much  to  say  that  peruse  these  lectures  and  acquaint  himself 
Dr.  Bennett  marks  an  era  in  the  science  and  with  the  disco  eries  of  so  ardent  an  explorer 
practice  of  medicine.  To  him  as  much  as  to  in  the  field  of  medicine."—  New  York,  Jovrnal 
any  other  physician,   are    due    the    changes  I  of  Medicine. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Manuals. 


Code  of  Medical  Ethics 

ADOPTED   BY    THE    AMERICAN    MEDICAL    ASSOCIATION. 

One  volume,  32mo,  39  pages,  muslin.     Price,  40c. 


Revised  to  date. 


Bigelow,  Jacob,  M.D., 


Physician  and  Lecturer  on  Clinical  Medicine  in  the  Massachusetts  General  Hospital ;  Professor  of  Mate- 
ria Medica  in  Harvard  University ;  President  of  the  American  Academy  of  Arts  and  Sciences, 
and  late  President  of  the  Massachusetts  Medical  Society. 

BRIEF  EXPOSITION  OF  RATIONAL  MEDICINE.  To  which  is  prefixed  The 
Paradise  of  Doctors.  A  Fable.  One  volume,  12nio,  69  pages,  muslin.  Price, 
50c. 

NATURE  IN  DISEASE.  Illustrated  in  various  Discourses  and  Essays.  To  which 
are  added  Miscellaneous  Writings,  chiefl}'  on  medical  subjects.  Latest  edition, 
enlarged.     One  volume,  12mo,   407  pages,    muslin.Price,  $1.25. 


Hooper's 


PHYSICIAN'S  VADE  MECUM  :  A  Manual  of  the  Principles  and  Practice  of  Physic  ; 
with  an  Outline  of  General  Pathology,  Therapeutics,  and  Hygiene.  Tenth  Edi- 
tion. Revised  by  William  Augustus  Guy,  M.B.,  Cantab.^F.R  S.,  and  John 
Harlet,  M.D.,  Lond.,  F.L.S.  Volumes  I.  and  II.  Illustrated  by  wood- en- 
gravings.    Sold  only  by  subscription.     See  page  52. 


Curtis,  Edward,  A.M.,  M.D., 


MANUAL  OF  GENERAL  MEDICINAL  TECHNOLOGY,  INCLUDING  PRE- 
SCRIPTION WRITING.  One  volume,  32mo,  334  pages,  fine  muslin.  Price, 
$1.00.     Wood's  Pocket  Manuals. 

"  The  metric  system  is  explained  in  a  man-  '  patience.  It  is  what  many  want  and  most 
ner  at  once  lucid  and  attractive,  and  -will  no  need. " — St.  Louis  Medical  Journal,  January, 
doubt  accomplish  much  in  the  way  of  render-    1884. 

ing  this  method  less  distasteful  to  those  who  "  A  very  important  feature  of  the  work  is 
have  given  it  but  little  attention. " — The  Medi-  its  clear  exposition  of  the  relations  of  the  Eng- 
cal  Bulletin,  Philadelphia,  Pa.,  January,  1881.  '  lish  apothecaries'  weights  and  measures  to  the 

"This  little  manual  is  a  tersely  composed  metrical  forms  now  so  often  seen  in  the  recent 
treatise  on  the  subjects  referred  to  alone,  in  a  text-books  and  medical  periodicals."  —  The 
convenient  and  authoritative  sort  of  way  that  Medical  Herald,  Louisville,  Ky.,  February, 
renders  it  a  handy  conservator  of  time  and  >  1884. 


Roosa,  D.  B.  St,  John,  M.D., 


Professor  of  the  Diseases  of  the  Eye  and  Ear  in  the  University  of  New  York. 

A  YEST-POCKET  MEDICAL  LEXICON.  Being  a  Dictionary  of  the  Words,  Terms, 
and  Symbols  of  Medical  Science.  Collated  from  the  best  authorities,  with  the 
additions  of  words  not  before  introduced  into  a  Lexicon.  With  an  Appendix. 
Third  revised  and  enlarged  edition.  One  volume,  64mo.  Price,  roan,  75c,  or 
tucks,  $1.00. 

EJ5P*°  This  is  just  what  its  title-page  would  indicate,  a  very  neat  and  convenient  medical 
dictionary,  so  small  that  the  student  can  carry  it  in  his  pocket  with  perfect  ease.  This  little 
book  has  received  the  warmest  commendations  from  very  many  of  the  best  medical  teachers 
in  the  United  States. 


"The  Lexicon  measures  three  and  one- 
fourth  inches  in  length,  by  two  and  three- 
e  ghths  in  breadth,  and  is  three-fourths  of  an 
inch  thick.  The  whole  work  is  well  done." — 
New  York  Teacher. 

"This  is  the  smallest  of  books,  albeit  an  ex- 


tensive Lexicon.  As  its  title  implies,  it  can 
nestle  snugly  in  the  vest  pocket.  To  any  one 
who  would  like  to  carry  about  his  person  a 
dictionary  of  medical  words  it  is  the  very 
thing." — Pacific  Medical  and  /Surgical  Jour- 
nal, 


10  PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Manuals,  Cyclojxedice,  etc. 
Tidy,  Charles  Meymott,  M.D.,  F.C.S., 

Master  of  Surgery,  Professor  of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London 
Hospital,  .Medical  Officer  of  Health  for  Islington  ;  late  Deputy  Medical  Officer  of  Health  and  Public 
Analyst  for  thr  City  of  London,  etc. 

LEGAL  MEDICINE.  Volume  I.  With  two  colored  plates.  Contents:  Evidence— 
The  Signs  of  Death — Identity — The  Causes  of  Death — The  Fost-morteni.  Sold 
by  subscription  only.     See  page  54. 

LEGAL  MEDICINE.  Volume  II.  Contents:  Expectation  of  Life — Presumption  of 
Death  and  Survivorship— Heat  and  Cold — Burns — Ligaturing —Explosives — 
Starvation — Sex — Monstrosities — Hermaphrodism.  Sold  by  subsdrijjtion  only. 
See  page  54 

LEGAL  MEDICINE  Volume  III.  Contents:  Legitimacy  and  Paternity— Preg- 
nancy. Abortion — Eape,  Indecent  Exposure — Sodomy.  Bestiality — Live  Birth, 
Infanticide — Asphyxia,  Drowning — Hanging,  Strangulation — Suffocation.  Sold 
by  subscription  only.     See  page  52. 

Castle,  Frederick  A.,  M.D.,  New  York. 

WOOD'S  HOUSEHOLD  PRACTICE  OF  MEDICINE,  HYGIENE,  AND  SURGERY. 
A  Practical  Treatise  for  the  Use  of  Families,  Travellers,  Seamen,  Miners,  and 
others.  By  Various  Authors.  In  two  volumes,  royal  8vo,  819  and  942  pages, 
illustrated  by  six  hundred  and  thirty-five  fine  wood-engravings.  Price,  per  vol- 
ume, muslin,  $5.00;  leather,  $6.00;  half  morocco,  $7.50.  Sold  by  subscrip- 
tion only. 

Ziemssen,  H.  Von,  M.D.,  Munich. 

CYCLOPAEDIA  OF  THE  PRACTICE  OF  MEDICINE.  By  Various  Authors.  Coni- 
plete  in  twenty  volumes,  royal  8vo.  Price  per  volume,  in  muslin,  §5.00  ;  in 
leather,  $0.00  ;  in  half  morocco,  $7.50.  Sold  by  subscription  only.  See  page 
63. 

Peabody,  George  L.,  M.D.,  New  York. 

SUPPLEMENT  TO  ZIEMSSEN'S  CYCLOPEDIA  OF  THE  PRACTICE  OF  MED- 
ICINE. By  Various  Authors.  In  one  royal  8vo  volume,  844  pages,  bound  to 
correspond.  Price,  in  cloth,  $6.00  ;  in  leather,  $7.00  ;  in  half  morocco,  $8.00  ; 
also  extra  muslin  (not  corresponding),  $6.00  ;  and  in  red  leather,  $7.00. 

E5F*  The  aim  of  this  work  is  to  take  up  each  subject  treated  of  in  Ziemssen's  Cyclopedia, 

and  to  bring  it  down  to  date.     Many  of  the  articles  will,   therefore,  embrace  the  progress  of 

it  some,  relating  to  the  later  volumes  of  Ziemssen,  begin  at  a  more  recent  period  ; 

tin-  whole,  however,  forms  a  complete  resume  of  the  progress  of  medicine  mostly  for  the  past 

five  years. 

Carpenter,  Wesley  M  ,  M.D., 

Bellevne  Hospital  ;  Tnstructorin  the  Pathological  Laboratory  of  the  University 
of  the  City  of  New  York  ;  Secretary  of  the-  Medical  .Society  of  the  County  of  New  York  ;  Secretary 
of  the  New  York  Pathological  s.>ciuty,  etc. 

!\'hi;\  OF  THE    PRACTICE   OF    MEDICINE.      Sold  only  by  subscription. 
i*>4. 

Flint,  Austin,  M.D. 

COMPENDIUM  OF  PERCUSSION  AND  AUSCULTATION  AND  OF  THE  PHYS- 
[CAL  DIAGNOSIS  OF  DISEASE8  AFFECTING  THE  LUNG  AND  HEART. 
(no-  volume,  L8mo,  48  pages,  muslin.     Price,  50  cents. 

Paul,  Dr.  Constantino, 

tli.    Faculty  of  Medicine  of  Taris.  etc. 

DIAGNOSIS  AND  DISEASES  OF   THE    HEART.      Illustrated  by  numerous  fine 
Sold  only  by  subscription.     See  page  52. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


11 


Practice,  Fevers. 


Loomis,  Alfred  L.,  M.D.,  LL.D., 


Professor  of  Pathology  and  Practical  Medicine  in  the  Medical  Department  of  the  University  of  the  City 
of  New  York  ;  Visiting  Physician  to  Bellevue  Hospital,  etc. 

A  TEXT-BOOK  OF  PRACTICAL  MEDICINE.  One  handsome  8vo  volume  of  over 
1,100  pages,  illustrated  by  two  hundred  and  eleven  engravings.  Price,  in  cloth, 
$6.00;  leather,  $7.00. 


"  The  work  before  us  is  a  complete  compre- 
hensive treatise  on  general  pathology  and 
practical  medicine.  The  arrangement  and 
classification  is  that  which  the  author  has  ob- 
served in  teaching,  and  is  based  on  advanced 
pathological  knowledge." — Louisville  Medical 
Nt  ws,  November  22,  1884. 

"  A  careful  examination  of  the  book  creates 
the  impression  that  it  is  the  work  of  one  who 
speaks  that  which  he  himself  knows.  It  is 
not,  as  is  too  often  the  case  in  such  works,  a 
mere  revamping  of  statements  which  have  been 
perpetuated  through  a  long  series  of  treatises 
ou  the  practice  of  medicine." — Medical  Age, 
Detroit,  October  25,  1SS4. 

"  The  work  traverses  the  usual  field  of  in- 
ternal pathology  considered  in  text-books 
upon  the  practice  of  medicine  ;  but  it  does  so 


with  evidences  of  such  unusual  discretion  and 
skill  as  to  present  the  subject  in  a  fresh  light, 
and  to  constitute  a  most  acceptable  addition 
to  medical  literature.  The  illustrations  are 
abundant,  original,  and,  as  a  rule,  neatly 
drawn,  and  well  illustrate  the  text,  in  which 
the  subjects  are  discussed  in  the  light  of  the 
most  recent  additions  to  our  knowledge  of 
pathology  and  therapeutics." — The  Philadel- 
phia Medical  Times,  December  27,  1884. 

"  It  is  an  elaborate  work  of  1,102  pages,  with 
a  full  index,  and  is  issued  in  the  publisher's 
best  style.  It  must  be  rated  as  one  of  the 
standard  works  on  the  theory  and  practice  of 
medicine  in  this  country,  and  should  have  a 
preference  over  those  emanating  from  Europe, 
even  if  re-edited  in  this  country." — The  Ther- 
apeutic Gazette,  November,  1884. 


LECTURES  ON  DISEASES  OF  THE  RESPIRATORY  ORGANS,  HEART  AND 
KIDNEYS.  One  volume,  8vo,  591  pages.  Price,  muslin,  $5.00 ;  leather, 
$6.00. 


"It  is  clear  in  style,  convenient  in  arrange- 
ment, very  definite  and  practical  in  its  teach- 
ings."*— Philadelphia  Medical  Times. 

"  We  like  the  systematic  method  in  which 
these  lectures  are  arranged,  and  regard  them 
as  excellent  in  every  way." — Cincinnati  Lan- 
cet and  Observer. 

"In  the  one  before  us  the  reader  may  look 
confidently  for  the  last  words  on  the  subject, 
and  may  rest  assured  that  what  the  author 
has  here  committed  to  the  press  is  the  result 
of  much  learning,  sound  judgment,  and  thor- 
ough experience." — American  Practitioner. 


"We  have  no  hesitation  in  pronouncing  it 
one  of  much  value  to  the  profession,  and 
highly  creditable  to  the  author." — New  York 
Medical  Journal. 

"While  the  views  presented  are  fully  up  to 
what  is  actually  known  on  the  subjects 
treated,  the  doctrines  are  judicious  and  safe. 
At  the  same  time  they  are  presented  with  un- 
usual clearness,  and  with  sufficient  positive- 
ness  to  command  confidence." — New  Orleans 
Medical  and  Surgical  Journal. 

"By  all  means  buy  Loomis'  work  and  study 
it." — Ohio  Medical  and  Surgical  Reporter. 


LECTURES  ON  FEVERS.     One  volume,  8vo,  403  pages.     Price  in  muslin,  $4.00. 


"  We  have  before  us,  therefore,  a  book  con- 
taining statements  of  practical  facts  relating 
to  certain  diseases,  and  the  theories  regarding 
their  nature,  mode  of  origin,  and  propagation, 
and  arranged  so  as  to  be  easily  comprehended 
by  the  medical  student.  We  also  believe  they 
will  be  read  without  weariness  by  the  daily 
practitioner.  ...  It  contains  much  prac- 
tical knowledge,  and  cannot  fail  to  be  read  by 
a  very  large  proportion  of  the  medical  profes- 
sion ;  for  a  concise  statement  of  facts — with 
only  such  qualifications  as  can  be  safely  in- 
dulged in  without  endangering  perspicuity 
— is  always  acceptable." — The  Medical  Rec- 
ord. 

"This  last  work  of  Professor  Loomis1  is  a 
valuable  contribution  to  medical  literature. 
His  treatment  of  the  subject  is  mainly  practi- 
cal, and  is  in  strict  conformity  with  what  the 
author  has  himself  observed  at  the  bedside. 
The  general  management  of  fever  is  justly  re- 
garded of  greater  importance  than  the  admin- 


istration of  drugs.  It  is  a  book  that  will  well 
repay  careful  study." —  Western  Lancet. 

"  The  work  is  clearly  and  concisely  written, 
and  will  be  useful  and  acceptable  to  both  stu- 
dent and  practitioner." — New  York  Medical 
Jour  no1, 

"  In  this  interesting  volume,  which  contains 
the  lectures  on  fevers  delivered  by  Professor 
Loomis  to  his  class  during  the  last  year,  we 
have  a  concise  and  impartial  review  of  the  lit- 
erature concerning  fevers  which  has  been  pub- 
lished since  1850,  with  reference  to  a  few 
older  books,  'because  they  contain  many  of 
the  so-called  new  theories  and  modes  of  treat- 
ing fevers.'  In  this  are  embodied  the  results 
of  the  author's  own  extensive  clinical  expe- 
rience, which  has  led  him  to  form  opinions  in 
certain  respects  at  variance  with  those  of 
some  other  observers  ;  and  the  weak  points  of 
theories  and  modes  of  practice  which  have  not 
stood  the  test  of  time  are  clearly  set  forth." 
— Lotito7i  Medical  and  Surgical  journal. 


la 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


Diseases  of  Throat  and  Chest,  of  the  Rectum. 


Corson,  John  W.,  M.D., 


Late  riiysician  to  the  class  of  "  Diseases  of  the  Chest  and  Throat"  in  the  New  York  and  Eastern  Dis- 
pensaries; formerly  Physician  to  the  Brooklyn  City  Hospital ;  Physician  to  the  Orange  Memorial 
Ho*pital,  etc. 

ON  THE  TREATMENT  OF  PLEURISY.  With  an  Appendix  of  Cases,  showing 
the  Value  of  Combinations  of  Croton  Oil,  Ether,  and  Iodine,  as  Counter-irritants 
in  otlier  Diseases.     One  volume,  16mo,  31  pages,  muslin.     Price,  50c. 


Ingals,  E.  Fletcher,  A.M.,  M,D., 


Lecturer  on  Diseases  of  the  Chest  and  Physical  Diagnosis,  and  on  Laryngology  in  the  Tost-gradnate 
Course,  Rush  Medical  College ;  Clinical  Professor  of  Diseases  in  the  Throat  and  Chest,  Woman's 
Medical  College  :  Physician  and  Surgeon  for  Diseases  of  the  Throat  and  Chest,  Central  Free  Dis- 
pensary, Chicago. 

LECTURES  ON  THE  DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF  THE 
CHEST,  THROAT,  AND  NASAL  CAVITIES.  With  one  hundred  and  thirty- 
five  illustrations.     One  volume,  8vo,  437  pages,  muslin.     Price,  $4.00. 


"  In  bringing  within  one  pair  of  book  covers 
a  concise  epitome  of  affections  of  the  chest 
and  the  entire  respiratory  tract,  Dr.  Ingals  has 
recognized  the  interdependent  relations  of  a 
group  of  anatomical  regions  falling  together 
naturally,  both  in  histology  and  pathology. 
His  volume  aims  thereby  at  an  objective  com- 
pleteness which  has  not  hitherto  been  attained, 
to  our  knowledge,  in  any  single  work  of  physi- 
cal diagnosis,  or  on  any  disease  of  the  chest 
and  air  -passages. " — American  Journal  of  the 
Medical  Sciences. 

"For  good,  practical,  and  correct  teaching, 
this  book  has  ne  superior.  There  is  no  volume 
which  would  be  more  useful  in  the  general 
practitioner's  daily  life." — American  Medical 
Wi  ■  Irly. 

"  This  forms  a  valuable  aid,   both  to   the 


student  and  practitioner,  in  the  study  of  its 
subject.  It  is  clear  and  concise  in  style,  sys- 
tematic and  thorough  in  the  consideration  of 
each  detail." — Chicago  Medical  Journal  and 
Examiner. 

'•  Both  as  to  the  matter  and  arrangement  of 
the  book,  it  must  be  of  great  service  to  the  or- 
dinary physician  as  well  as  to  the  specialist." 
—  Virginia  Medical  Monthly. 

"The  work  is  of  the  most  practical  charac- 
ter ;  it  avoids  theoretical  and  unsettled  ques- 
tions ;  the  subjects  are  presented  in  a  lucid 
and  compact  style.  We  predict  for  this  work 
a  wide  field  of  usefulness  because  it  seems  to 
us  to  be  exactly  adapted  to  the  use  of  the  phy- 
sician in  active  practice." — Maryland  Medical 
Journal. 


Kelsey,  Charles  D.,  M.D., 


Surgeon  to  ?t.  Paul's  Infirmary  for  Diseases  of  the  Rectum  ;  Consulting  Surgeon  for  Diseases  of  the 
Rectum  to  the  Harlem  Hospital  and  Dispensary  for  Women  and  Children,  etc.,  etc. 

THE  PATHOLOGY,  DIAGNOSIS,  AND  TREATMENT  OF  DISEASES  OF  THE 
RECTUM  AND  ANUS.  One  volume,  8vo,  430  pages,  illustrated  by  two 
chromo  lithographic  plates  and  many  wood-engravings.     Price,  in  cloth,  $4.00, 


''The  aim  of  the  author  has  been  to  make 
this  boob  a  Bafe  guide  for  the  student  and  gen- 
Mai  practitioner,  and  to  furnish  that  informa- 
tion which  is  bo  difficult  to  obtain  without 
special  advantages,  such  as  are  obtained  by 
clinic,,  i  fcc." 

"  In  oonclnaion,  we  will  add  that  the  author 
has  sue-,  i  ded  admirably  in  giving  us  a  book 
which  will  greatly  advance  the  domain  of  rec- 
tal Burgery,  and  encourage  many  a  practitioner 
who  baa  heretofore  shrunk  from  this  distaste- 
ful and  unsatisfactory  branch  of  surgery,  to 
it  again  with  renewed  confidence." — 
North  Carolina  M> dual  Journal. 


"  It  forms  the  best  recent  work  on  a  class  of 
disease  which,  although  claimed  by  surgery, 
has  more  medical  relation  than  most  physi- 
cians are  aware." — The  College  and  UlinieRec- 
ord. 

"  The  work  is  an  excellent  one,  and  will  be 
highly  appreciated." — The  Physicians'  and 
Surgeons'  investigator. 

'"The  student  and  busy  practitioner  will 
find  here  in  a  condensed  form  all  that  is  posi- 
tively known,  and  much  that  has  not  before 
been  recorded,  concerning  diseases  of  the  rec- 
tum and  anus." — The  Medical  Bulletin,  Phil- 
adelphia, Pa. 


si.S    OF    THE    RECTUM    AND    ANUS. 
j  a  e  54. 


Sold  only  by  subscription.     See 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


13 


Diseases  of  the  Hectum  and  Anus,   Therapeutics. 
Bodenhamer,  William,  M.D., 

Professor  of  the  Diseases,  Injuries,  and  Malformations  of  the  Rectum,  Anus,  and  Genito-Urinary  Or- 
gans. 

TREATISE  ON  THE  HEMORRHOIDAL  DISEASE.  Giving  its  History,  Nature, 
Cause,  Pathology,  Diagnosis,  and  Treatment.  One  volume,  8vo,  over  800  pages, 
illustrated  by  two  chromo-lithographic  plates  and  many  wood-cuts.  Price,  mus- 
lin, $3.00. 

"  It  is  a  practical  discourse  on  both  the  surgical  and  medical  treatment  of  hemorrhoids, 
and  if  well  studied  will  enable  any  medical  man  of  ordinary  capacity  to  manage  all  such 
cases." — Therapeutic  Gazette,  December,  1884. 

A  PRACTICAL  TREATISE  ON  THE  AETIOLOGY,  PATHOLOGY,  AND  TREAT- 
MENT  OF    THE   CONGENITAL    MALFORMATIONS    OF    THE    RECTUM 

AND  ANUS.  "  Necessitas  medicinum  invenit  experientia  perfecit"  (Hippoc- 
rates). Illustrated  by  sixteen  plates  and  exemplified  by  287  cases.  One  vol- 
ume,  8vo,  368  pages,  muslin.     Price,  $4.00. 

''Must  be  considered  by  far  the  most  valuable,  if  not  the  only  text-book  on  this  subject." — 
Boston  Medical  and  Surgical  Journal. 

PRACTICAL  OBSERVATIONS  ON  THE  ^ETIOLOGY,  PATHOLOGY,  DIAGNO- 
SIS, AND  TREATMENT  OF  ANAL  FISSURE.  Illustrated  by  numerous 
cases  and  drawings.     One  volume,  8vo,  199  pages,  muslin.     Price,  $2.25. 


"The  treatise  is  throughout  carefully  pre- 
pared, and  we  recommend  it  as  a  valuable, 
practical  book,  worth  the  place  in  any  work- 
ing library." — Medical  and  Surgical  Reporter. 

"This  is  the  most  complete  and  extensive 
treatise  on  this  very  painful  and  troublesome 
disease.  The  work  is  really  a  history  of  the 
disease,  comprising  an  accurate  description  of 
its  symptoms  and  pathology,  together  with 
the  plan  of  treatment.     As  is  the  case  with  all 


specialties,  when  treated  in  a  separate  volume, 
we  get  the  subject  in  an  extended  and  minute 
form." — St.  Louis  Medical  Reporter. 

' '  It  will  be  perused  with  interest  and  profit 
by  all." — Detroit  Review  of  Medicine,  etc. 

"We  believe  that  the  subject  has  received 
full  justice  at  the  hands  of  the  author,  and. 
that  the  work  will  be  the  standard  on  the 
subject." — Buffalo  Medical  and  Surgical  Jour- 
nal. 


THE  PHYSICAL  EXPLORATION  OF  THE  RECTUM.  With  an  Appendix  on 
the  Ligation  of  Hemorrhoidal  Tumors.  Illustrated  by  numerous  drawings. 
One  volume,  8vo,  54  pages,  muslin.     Price,  $1.25. 

AX  ESSAY  ON  RECTAL  MEDICATION.  One  volume,  8vo,  58  pages,  illustrated, 
muslin.     Price,  $1.00. 

ISf3  In  the  employment  of  an  official  therapeutic  remedy,  it  is  not  only  important  and 
necessary  to  know  in  what  case,  in  what  dose,  in  what  form,  but  also  by  what  channel  it  should 
be  administered. 


Ringer,  Sidney,  M.D., 


Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College  ;  Physician  to  University 
College  Hospital. 

A  HANDBOOK  OF  THERAPEUTICS  WITH   DIETARY  AND   INDEX  OF  DIS- 
EASES.    Tenth  edition.     Price,  $5.00. 


"  Upon  the  appearance  of  that  now  indis- 
pensable work,  '  Ringer's  Handbook  of  Thera- 
peutics.'  my  attention  was  particularly  at- 
tracte  I  to  the  frequency  with  which  he 
recommends  small  doses  of  medicines  that  we 
have  been  accustomed  to  use  in  much  larger 
doses  for  entirely  different  diseases.  Some  of 
these  remedies  were  recommended  so  strongly, 


the  opportunity  of  further  testing  them  in 
numerous  cases  of  adults." — Dk.  Desseau  in 
Medical  Record,  July  28,  1877. 

"  The  author  has  selected  everything  of  sub- 
stantial value  among  the  recent  advances  in 
therapeutics.  It  is  a  practical  work,  replete 
with  interest  and  reliable  information,  and 
will  be  found  to  be  one  which  can  be  consulted 


that  I  was  induced  to  give  them  a  trial,  more  |  by  the  practitioner  with  much  benefit.  We 
especially  as  my  practice  among  children  com-  would  advise  every  young  physician  to  pro- 
pels me,  for.  many  reasons,  to  administer  as  cure  and  read  the  book.  It  fills  all  the  author 
little  unple.isant-tasting  medicines  as  possible,  r  claims  for  it  in  letter  and  spirit,  and  is  written 
Their  use  with  children  first  having  been  in  such  a  clear  and  simple  style  that  all  who 
found  satisfactory,  my  position  in  connection  read  it  will  do  so  with  pleasure." — Western 
with  the   New  York  Dispensary  afforded  me    Lancet. 


U  PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Materia  Med  lea,  Therapeutics. 
Eothergill,  J.  Milner,  M.D., 

Member  of  the  Royal  College  of  Physicians  of  London  ;  Senior  Assistant  Physician  to  the  City  of  Lon- 
don Hospital  for  Diseases  of  the  Chest  (Victoria  Park) ;  late  Assistant  Physician  to  the  West  Lon- 
don Hospital ;  Associate  Fellow  of  the  College  of  Physicians  of  Philadelphia. 

INDIGESTION,  BILIOUSNESS,  AND  GOUT  IN  ITS  PROTEAN  ASPECTS. 
Part  I.  Indigestion  and  Biliousness.  One  volume,  12mo,  320  pages,  muslin. 
Pi  ice,  $2.25. 

"  The  relation  of  digestion  to  habits  of  life,  i  four  chapters  are  devoted  to  its  functions  and 
to  methods  of  living,  and  to  the  perfect  nutri-  j  their  disturbances.  In  referring  to  the  in- 
tion  of  the  body,  are  treated  in  a  masterly  |  fluence  of  mental  strain  and  worry,  Dr.  Foth- 

ergill  says:  'Talking  one  day  with  3Ir.  Van 
Abbott,  whose  biscuits  for  diabetic;  have  such 
a  well-deserved  renown,  I  asked  him,  "Who 
are  your  diabetics  mostly?"  The  reply  was 
very  significant.  "Business  men,  compara- 
tively old  and  gray  for  their  years  ;  men  who 
look  as  if  they  had  a  deal  on  their  minds.'' 
This  was  the  response.  It  stands  in  sugges- 
tive relationship  to  the  fact  of  acute  diabetes 


manner,  and  abound  in  practical  hints  of  the 
greatest  possible  utUity  to  the  practising  phy- 
sician. Altogether,  the  work  is  a  remarkably 
comprehensive  study  of  a  subject  which  is  too 
little  understood  by  the  majority  of  medical 
men." — New  York  Medical  Record. 

"  Dr.  Fothergill's  writings  always  command 
attention ;  they  are  sprightly  and  full  of  in- 
structive facts,  drawn  mostly  from  his  own 

large  experience.      This    volume    is    written  j  being  set  up  by  shock  or  other  mental  pertnr 
from  a  physiological  standpoint,  and  begins  !  bation,  or  of  its  artificial  production  by  the 


puncture  of  the  floor  of  the  fourth  ventricle.' 
The  whole  book  is  practical  and  interesting 
reading." 


with  an  account  of  natural  digestion,  by  way 
of  introduction  or  antithesis  to  the  main  topic 
of  the  book.  As  the  liver  is  the  great  store- 
house of  supplies  for  the  use  of  the  system, 

Phillips,  Charles  D.  F.,  M.D.,  F.R.C.S.E., 

Lecturer  on  Materia  Medica,  Westminster  Hospital,  London. 

MATERIA  MEDICA  AND  THERAPEUTICS.  Inorganic  Substances.  Adapted  to 
the  United  States  Pharmacopoeia  by  Lawrence  Johnson,  M.D.  Volumes  I. 
and  II.    Sold  only  by  subscription.     See  page  54. 

MATERIA  MEDICA  AND  THERAPEUTICS.  Vegetable  Kingdom.  Revised  and 
adapted  to  the  U.  S.  Pharmacopoeia  by  Henry  G.  Piffard,  A.M.,  M.D..  Pro- 
fessor of  Dermatology,  University  of  the  City  of  New  York  ;  Surgeon  to  the 
Charity  Hospital,  etc.,  etc.  This  practical  book  forms  a  volume  in  this  series 
of  327  pages. 

Garrod,  Alfred  Baring,  M.D.,  F.R.S., 

Fellow  of  the  Royal  College  of  Physicians,  etc.,  etc., 

THE  ESSENTIALS  OF  MATERIA  MEDICA  AND  THERAPEUTICS.  One  hand- 
some Svo  volume,  439  pages,  extra  muslin.     Price,  $4.00. 

"The  author  of  this  book  has  succeeded  i  "  We  have  here  a  brief  resume  of  materia 
admirably  in  placing  in  concise  form  what  is  medica,  all  non-essential  parts  being  omitted. 
sury  to  be  known  of  materia  medica  and  It  might  be  called  a  commentary  on  the  Pbar- 
thcrapeutics,  leaving  it  to  larger  works  to  j  macopoeia,  as  it  somewhat  resembles  Phillips' 
enter  into  details.  ...  If  our  estimate  commentary  on  the  London  Pharmacopoeia, 
of  the  work  is  a  correct  one,  and  we  think  it 
is,  it  will  not  be  long  before  another  edition 
will  be  called  for." — Medical  and  Surgical 
Reporter. 


though  more  extended  in  its  description  of  the 
action  and  uses  of  remedies." — Eclectic  Medi- 
cal Journal. 


Trousseau,  A.,  M.D., 

Pn  >f '   a  x  of  Therapeutic*  of  the  Faculty  of  Medicine  of  Paris ;  Physician  to  the  l'H&tel  Lieu,  etc.,  etc. 

THERAPEUTICS.  Translated  by  D.  F.  Lincoln,  M.D.,  from  the  Materia  Medica 
and  Therapeutics.  Ninth  French  Edition,  revised  and  edited.  Volume  I.,  II., 
and  III.     Sold  by  subscription  only.     See  page  56. 

Any  work  by  Trousseau  needs  no  introduction  to  the  medical  profession— his  profound 

iity  of  imparting  instruction,  and  his  delightful  style  commend 

nam.;  to  their  best  consideration.     This  work  is  said  to  be  superior  to  any 

i.ject,  and  one  which  will  long  continue  to  be  a  standard.     The  edition  from 

which  this  translation  is  made  has  been  thoroughly  revised  and  edited  by  Dr  Paul,  and  brought 

down  to  the  present  year. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


15 


Therapeutics,   Gholera,  Diagnosis. 


Binz,  C,  M.D., 


Professor  of  Pharmacology  in  the  University  of  Bonn. 

THE  ELEMENTS  OF  THERAPEUTICS.  A  Clinical  Guide  to  the  Action  of  Medi- 
cines. Translated  from  the  Fifth  German  Edition,  and  Edited,  with  Additions, 
in  conformity  with  the  British  and  American  Pharmacopoeias,  by  Edward  I. 
Sparks,  M.A.,  M.B.,  Oxon. ,  Member  of  the  Royal  College  of  Physicians  of 
London,  Officier  de  Sante  (Alpes  Maritimes),  France,  formerly  Radcliife  Travel- 
ling Fellow.  In  one  handsome  12mo  volume,  345  pages.  Bound  in  extra  mus- 
lin.    Price,  $2.00. 


"Fully  up  to  the  times  as  a  therapeutic 
guide." — Toledo  Medical  and  Surgical  Jour- 
nal. 

"We  are  much  mistaken,  however,  if  the 
work  in  its  present  shape  does  not  become  a 
general  favorite  with  both  students  and  prac- 
titioners.    It  will  also  help,  we  think,  to  ad- 


vance the  movement  to  establish  an  universal 
Pharmacopoeia." — New  Remedies. 

' '  The  work  appears  to  have  been  written 
with  great  care,  and  bears  the  impress  of  re- 
liability, and  is  a  volume  that  we  do  not  he»i- 
tate  to  recommend  in  the  strongest  maimer." 
— The  Medical  Record. 


Wendt,  Edmund  C,  M.D., 

Curator  of  St.  Francis'  Hospital ;  Pathologist  and  Curator  of  the  New  York  Infant  Hospital,  etc. 

A  TREATISE  ON  CHOLERA.  Edited  and  Prepared  in  Association  with  John  C. 
Peters,  M.D.,  New  York,  John  B.  Hamilton,  M.D.,  Surgeon-General  U.  S. 
Marine  Hospital  Service,  and  Ely  McClellan,  M.D.,  Surgeon  U.  S.  Army. 
Illustrated  with  maps  and.  engravings.     Sold  only  by  subscription.    See  page  51. 


__  '  Availing  themselves  of  the  history  and  experience  of  cholera  epidemics  to  the  present 
day,  together  with  the  new  light  thrown  upon  its  mode  of  propagation,  spread,  and  treatment 
the  past  year  through  the  investigations  of  Prof.  Koch  and  others — the  knowledge  concerning 
preventive  measures,  quarantine,  etc. ,  so  recently  acquired  in  France  and  Italy — the  learned 
authors  of  this  work  aim  to  produce  a  book  which  may  at  least  serve  to  prepare  the  profession 
of  America  successfully  to  combat  this  dreaded  scourge,  should  it  unfortunately  gain  an  en- 
trance into  our  country  this  year. 


Burrall,  F.  A.,  M.D., 

ASIATIC  CHOLERA.     One  volume,  12mo,  155  pages,  muslin.     Price,  $1.50. 


"  It  is  a  special  merit  of  Dr.  Burrall's  timely 
volume,  that  it  so  states  facts  as  to  instruct 
the  reader  most  impressively  and  acceptably 
in  all  that  relates  to  preventive  measures  and 
prophylaxis.  We  have  met  with  no  writing  on 
cholera  in  our  language  that  has  more  happily 


achieved  this  chief  end  of  medical  research. 
For  this  reason,  no  less  than  for  the  scholarly 
excellencies  of  this  brochure,  it  is  sure  to  com- 
mand the  attention  and  regard  of  the  profes- 
sion."— Medical  Record. 


Brown,  Harvey  E.,  M.D., 

Assistant  Surgeon  United  States  Army. 

REPORT  ON  QUARANTINE  on  the  Southern  and  Gulf  Coasts  of  the  United  States. 
One  volume,  8vo,  117  pages,  muslin.     Price,  $1.25. 


Delafield,  Francis,  M.D. ;  and  Stillman,  Charles  F.,  M.D. 

A  MANUAL  OF  PHYSICAL  DIAGNOSIS.  Illustrated  with  superimposed  and 
transparent  lithographed  plates.  One  volume,  4to,  30  pages,  muslin.  Price, 
$2.00. 

"The- want  of  conciseness  in  ths  ordinary  i  "We  cannot  imagine  any  way  in  which  the 
manuals  on  physical  diagnosis  affects  the  aver-  ;  practical  study  of  ph  ysical'  diagnosis  can  be 
age  student,  and  they  never  learn  it  until  com-  made  more  easy  than  by  the  aid  of  this  su- 
pelled  to.  This  work  is  an  exception  to  this  perb  work." — Pacific  Medical  and  Surgical 
rule." — Ohio  Medical  Recorder.  '  Journal. 


16 


PUBLICATIONS  OF  WILLIAM  \YOOD  &  COMPANY. 


Diagnosis. 


Ranney,  Ambrose  L.,  A.M.,  M.D., 


Adjunct  Professor  of  Anatomy  and  Late  Lecturer  on  the  Surgical  Diseases  of  the  Genito- Urinary  Organs 
and  on  Minor  Surgery  in  the  Medical  Department  of  the  University  of  the  City  of  New  Tork  :  Late 
Surgeon  to  the  Northwestern  and  Northern  Dispeu saries;  ltesident  Fellow  of  the  New  York  Acad- 
emy of  Medicine ;  Member  of  the  Medical  Society  of  the  County  of  New  York,  etc. 

A  PRACTICAL  TREATISE  OX  SURGICAL  DIAGNOSIS.  DESIGNED  AS  A 
.MANUAL  FOR  PRACTITIONERS  AND  STUDENTS.  Third  Edition.  One 
volume  of  638  pages,  illustrated  by  31  plates,  handsomely  bound  in  muslin. 
Price,  §4.50. 


"Useful  on  account  of  its  systematic  ar- 
rangement."—  Cincinnati  Lancet  and  Clinic. 

■  •  We  are  at  a  loss  to  see  how  more  informa- 
tion could  have  been  condensed  in  fewer 
•words.'- — Chicago  Medical  Journal  and  Ex- 
it,-, int  r. 

"The  system  and  arrangement  of  the  vol- 
ume are  highly  commendable,  and  the  author 
has  carried  them  out  well." — Southern  Prac- 
titioner. 

"A  very  good  aid  to  surgical  diagnosis  for 
both  advanced  surgeons  and  beginners.  As  a 
text-book  for  surgical  lectures  it  is  quite  val- 
uable."— St.  Louis  Clinical  Record. 

"With  the  exception  of  Macleod's  'Out- 
lines,' published  simultaneously  in  England 


I  and  in  this  country,  in  1864,  this  is,  so  far  as 
,  we  know,  the  first  monograph  ever  issued  on 
I  surgical    diagnosis." — Philadelphia    Medical 
Times. 
"  The  chief  source  of  perplexity  in  the  prac- 
'  tice  of  medicine  and  surgery  is  to  find  out  what 
is  the  matter  with  the  patient.     Uncomfort- 
able, indeed,  is  the  reflection  of  a  practitioner 
when  he  has  left  a  case  bandaged  and  dressed 
for  a  fracture,  when,   perchance,  it  may  be  a 
dislocation.     Dr.  Ranney  has  given  us  a  book 
to  assist  us  in  all  such  states  of  uncertainty, 
and  he  has  done  well ;    for  in  presenting  the 
symptoms  of  disease  in  marked  contrast,  it 
makes  the  diagnosis  of  similar  troubles  really 
'  easy." — Toledo  Med.  and  Surg.  Journal. 


Guttman,  Dr.  Paul, 


Privat-Docent  in  Medicine.  University  of  Berlin. 

k  HANDBOOK  OF  PHYSICAL  DIAGNOSIS:  COMPRISING  THE  THROAT, 
THORAX,  AND  ABDOMEN.  Translated  from  the  Third  German  Edition  by 
ALEX.  Napiee,  M.D.,  Fellow  of  Faculty  of  Physicians  and  Surgeons,  Glas- 
gow. American  Edition,  with  a  colored  plate  and  numerous  illustrations. 
Sold  only  by  subscription.     See  page  56. 


Loomis,  Alfred  L.,  M.D., 

Professor  of  the  Institutes  and  Practice  of  'Medicine  in  the  Medical  Department  of  the  University  of 
New  York  :  Physician  to  Bellevue  and  Charity  Hospitals,  etc. 

LESSONS  IN"   PHYSICAL  DIAGNOSIS.     One  volume,  8vo,  240  pages,  illustrated, 
muslin.      Price,  $3.00. 


"  The  previous  editions  of  this  volume  have 
■  tv  well  received,  and,  from  their  ready 
gale,  appear  to  meet  a  well-recognized  want. 
We  find  the  plan  of  the  work  excel- 
nd,  within  the  limits  proposed  by  the 
v  rv   well    lurried    out.      It   would    bo 
to  point  out  many  omissions ;  complete- 
ness to  ■>  cei  tain  degree  ex- 
clude each  other  ;  bul  in  the  space  assumed  it 
would  ix-  difficult  to  include  a  greater  variety 
and  amount  of  sound  teaching.    Tin-  style  is 
■  ar.  positive,  and  exact.    It  i-  Er<  e 
from  all  irrelevant  b;  nothing  is  al- 

lowed to  disturb  or  confuse  the  distinct  image 
of  olil  ...     The  book  i«  very 

••  and  industrious  author  ; 
and  wl  !  practically  master  its  con- 

cannot  fail  to  l»  ;i  discriminating'  and 
well- furnished  diagnostician." — The  Medical 
/•'■  ■  ord. 

Lenta  it  is  the  best  work  on  physi- 


cal diagnosis  that  is  published." — Ditroit  lie- 
v'n  w  of  Medtcint . 

"This  is  a  work  already  well  and  favorably 
known  to  the  profession.  In  the  present  edi- 
tion the  original  text  has  been  entirely  revised 
and  enlarged  by  the  addition  of  five  new  les- 
sons."— Chicago  Medical  Examiner. 

"Students  of  medicine  and  practitioners 
will  find  this  just  the  work  to  meet,  their 
wants  on  the  s-ubjects  of  which  it  treats.  Its 
instructions  are  full  and  very  plain." — Cincin- 
nati Medical  X<  ws. 

"The  previous  editions  of  the  work,  con- 
fined to  an  exposition  of  the  subject  of  physi- 
cal exploration  of  the  chest  and  abdomen,  we 
have  regarded  as  among  the  very  best  works 
on  the  subject  extant,  and  hence  recommended 
'  Loomis  on  Physical  Diagnosis  '  to  our  classes  ; 
and  it  gives  vs  pleasure  to  repeat,  in  this  form, 
our  hearty  commendation  of  the  book."  — 
Michigan  University  Medical  Journal. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY.         17 


Botany,  Climatology,  and  Physiology. 


Johnson,  Laurence,  A.M.,  M.D., 

Lecturer  on  Medical  Botany,  Medical  Department  of  the  University  of  the  City  of  New  York  ;  Fellow 
of  the  New  York  Academy  of  Medicine,  etc. 

MEDICAL  BOTANY  :  A  Treatise  on  Plants  used  in  Medicine.  Illustrated  by  nine 
beautifully  colored  plates  and  very  numerous  fine  wood-engravings.  Sold  only 
by  subscription.     See  page  52. 


Bell,  A.  N.,  A.M.,  M.D., 


Editor  of  "  The  Sanitarian  ;  "  Member  of  American  Medical  Association,  American  Public  Health  Asso- 
ciation, Medical  Society  of  the  State  of  New  York  ;  Honorary  Member  of  Connecticut  Medical  Soci- 
ety ;  Corresponding  Member  of  the  Epidemiological  Society  of  London  ;  formerly  P.  A.  Surgeon 
U.  S.  Navy,  etc. 

CLIMATOLOGY   OF  THE   UNITED    STATES   AND    ADJACENT   COUNTRIES, 

and  of  sucb  Foreign  Ports  and  Places  as  bave  intimate  Commercial  Relations 
with  the  United  States,  with  special  reference  to  Health  Resorts,  and  the  Pro- 
tection of  Public  Health.     Sold  only  by  subscription.     See  page  51. 

rp^=  This  work  has  been  written  expressly  for  Wood's  Library,  by  one  whose  training  and 
stud}-  have  been  for  many  years  in  this  line. 


Fothergill,  J.  Milner,  M.D., 


Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest  (Victoria  Park)  ;  Hon.  M.D.  Rush 
College,  Illinois  ;  Associate  Fellow  of  the  College  of  Physicians,  Pennsylvania. 

THE  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS.      A  Work  for  Young  Practi- 
tioners.    Second  edition.     8vo,  256  pages.     Bound  in  muslin.     $2.25. 

"Skill  consists  of  foundation  of  common-sense  and  a  superstructure  of  special  education." 


Ashby,  Henry,  M.D., 


Physician  to  the  General  Hospital  for  Sick  Children,  Manchester  ;  Lecturer  on  Animal  Physiology  to 
the  Evening  Classes,  the  Owens  College  ;  formerly  Demonstrator  of  Physiology,  Liverpool  School  of 
Medicine. 

MEMORANDA  OF  PHYSIOLOGY.  Third  edition.  Thoroughly  revised,  with  ad- 
ditions and  corrections  by  an  American  editor.  18mo,  319  pages,  muslin. 
Price,  $1.00.     (Wood's  Pocket  Manuals.) 


"  This  valuable  addition  to  the  popular  se- 
ries, Wood's  Pocket  Manuals,  was  originally 
compiled  for  the  use  of  the  students  of  the 
Liverpool  School  of  Medicine,  when  preparing 


tions  embrace  concise  data  on  Physiological 
Chemistry,  Physiological  Histology,  The 
Blood,  The  Circulation,  Lymphatic  System, 
Respiration,   Animal  Heat,  Food,   Digestion, 


for  the  primary  examination  of  the  College  of  |  Absorption  and  Nutrition,  The  Liver,  The  Kid- 
Surgeons.  The  author  was  induced  to  bring  I  neys,  The  Ductless  Glands,  Nervous  System, 
them  out  in  print,  in  the  hope  that  they  might  :  The  Senses,  Speech,  and  Organs  of  Generation  ; 
prove  useful  to  a  wider  class  of  students.  I  and  the  Appendix ;  Ingesta  and  Egesta,  Metric 
Qiain's  and  Gray's  Anatomies  and  Foster's  j  System,  and  Thermometer  Scales.  A  'com- 
'  Text-book  of  Physiology  '  were  the  sources  plete  index  makes  the  usefulness  of  the  little 
upon  which  much  of  the  information  contained  !  book  readily  available." 
in  the  work  was  founded.     The  seventeen  sec- 

Comstock,  J.  C. ;  and  Comings,  N.,  M.D., 

PRINCIPLES  OF  PHYSIOLOGY  :  Designed  for  the  Use  of  Schools,  Academies, 
Colleges,  and  the  General  Reader.  Comprising  a  Familiar  Explanation  of  the 
Structure  and  Functions  of  the  Organs  of  Man.  Illustrated  by  comparative  ref- 
erences to  those  of  the  inferior  animals.  Also  an  essay  on  the  Preservation  of 
Health.  With  fourteen  quarto  plates  and  over  eighty  engravings  on  wood, 
making  in  all  nearly  two  hundred  figures.  One  volume,  4to,  110  pages.  Price, 
in  muslin,  uncolored,  $2.25. 

2 


IS         PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Physiology. 
Kirkes'  Handbook  of  Physiology. 

HANDBOOK  OF  PHYSIOLOGY.  By  W.  Morrant  Baker,  F.R.C.S.,  Surgeon  to 
St.  Bartholomew's  Hospital  and  Consulting  Surgeon  to  the  Evelina  Hospital  for 
Sick  Children  ;  Lecturer  on  Physiology  at  St.  Bartholomew's  Hospital,  and  late 
Member  of  the  Board  of  Examiners  of  the  Royal  College  of  Surgeons  of  Eng- 
land, and  Vincent  Dormer  Harris,  M.D.  Lond.,  Demonstrator  of  Physiol- 
ogy at  St.  Bartholomew's  Hospital.  Eleventh  edition.  In  one  volume,  with 
a  colored  •  plate  and  five  hundred  illustrations.  Price,  muslin,  $4.00;  leather, 
$5.00. 

|  ;  =  Kirkes'  Physiology  has  long  enjoyed  a  high  reputation,  as  one  of  the  best  and  most 
practical  works  of  its  kind,  and  in  this  new  edition,  just  completed  by  Drs.  Baker  and  Harris, 
is  probably  as  acceptable  a  book  on  the  subject  as  could  be  presented  to  the  practitioners  of 
America. 


".  .  Fully  up  to  the  latest  developments 
in  the  science  of  which  it  treats.  The  illus- 
trations are  well  selected  and  will  be  found 
very  helpful  to  the  student  in  his  efforts  to 
comprehend  and  master  even  the  most  intri- 
cate portions  of  the  subject." — The  Jlahne- 
mannian,  Phdadelphia,  Pa.,  July,  1885. 

"  Indeed,  the  order  of  subjects  and  arrange- 
ment of  matter  throughout  the  volume  are 
most  excellent,  and,  as  a  handbook,  the  ab- 
sence of  all  controversial  argumentation  on 
settled  points  is  an  additional  recommendation 
of  its  value.  The  illustrations  can  hardly  be 
called  beautiful,  but  they  are  well  drawn  and 
instructive,  and  this  is  the  chief  end  of  a  pict- 
ure in  a  work  on  physiology." — The  Amer- 
ican Practitioner,  Louisville,  Ky.,  June,  1885. 

"  The  book  before  us  is  a  revision  and  im- 
proved edition  of  Kirkes'  Physiology.  It  is  a 
very  excellent  work.  .  .  .  To  those  of  us 
who,  in  our  student  days,  paid  reverence  to 
the  teaching  of  Kirkes,  this  book  comes  as  a 
pleasant  reminder  of  an  old  friend,  and  pre- 
sents us  with  all  the  additional  discoveries  in 
this  branch  of  onr  science  which  have  been 
made  up  to  the  present  time.  We  very  cor- 
dially endorse  this  book." — The  Southern 
Clinic,  Richmond,  Va.,  April,  1885. 

"  This  old  standard  work  has  been  thor- 
oughly revised  and  brought  up  to  the  times. 
It  has  long  been  one  of  the  finest  books  for 
the  student  and  practitioner  and  will  long  con- 
tinue such.  This  edition  has  been  enhanced 
in  value  by  the  addition  of  a  large  number 
nf  most  excellent  woodcuts  and   the  text  has 

been  largely  rewritten." — New  England  Medi- 
cal Monthly,  April,  1885. 

Lambert,  T.  S.,  M.D., 


"As  a  guide  for  the  student,  and  ready  ref- 
■  erencefor  the  practitioner,  this  work  is  not  ex- 
celled by  any  other  in  the  English  language 
for  the  clearness  of  statement  of  established 
i  facts  in  the  science  of  which  it  treats." — The 
Sanitarian,  New  York,  April,  1885. 

"The  Messrs.  Wood  do  not  intend  to  forget 
the  juniors  and  give  them  therefore  the  best 
works  at  a  nominal  price.     There  is  hardly  a 
!  practitioner  of  some  years  who  did  not  learn 
the  principles  of  physiology  from  Kirkes,  and 
I  any  work  which  reaches  an  eleventh  edition, 
|  shows  its  intrinsic  value." — The  North  Amer- 
ican Journal  of  Homoeopathy,  Philadelphia, 
May,  1885. 

"Kirkes'  Handbook  has  been  a  popular 
text-!  ook  of  physiology  for  so  many  years 
that  its  eleventh  edition  hardly  calls  for  an 
extended  notice,  much  less  a  review.  It  is 
enough  to  say  that  the  editors,  who  are  now 
practically  the  authors,  have  maintained  the 
high  character  of  the  work,  and  have  kept  ful- 
ly up  to  the  times  in  the  science  of  physiology, 
which  has  made  such  vast  progress  within  the 
last  few  years." — GaillarcVs  Medical  Journal, 
May,  18S5. 

"On  carefully  looking  through  the  last  edi- 
tion of  Kirkes'  Physiology,  which  is,  however, 
really  Kirkes',  it  seems  to  us,  only  through  the 
courtesy  of  the  editors,  we  can  tind  scarcely 
anything  to  criticise.  It  seems  thoroughly  up 
to  the  time,  and  while  moot  points  in  physi- 
ology have  not  been  entirely  omitted,  they  are 
stated  in  such  a  way  as  to  render  them  easily 
comprehensible  to  the  youngest  student  of 
medicine." — The  Therapeutic  Gazette,  May, 
1885. 


PRIMARY  SYSTEMATIC  BUMAN  PHYSIOLOGY,  ANATOMY,  AND  HYGIENE. 
A  new  and  Improved  method  <>f  analysis  and  classification,  both  simple  .and 
complete,  practical  and  interesting.  Adapted  to  the  use  of  young  scholars.  One 
volume,  l»mo,  L 78  pages,  illustrated,  muslin.     Price,  85c. 


Brodie,  Sir  Benjamin,  Bart.,  D.C.L., 


hi  "I  the  Rival  Society. 

MEND  AND  MATTER;  or,  Physiological  Inquiries  in  a  Series  of  Essays,  intended 
to  illustrate  the  mutual  rotations  of  the  physical  organization  and  the  mental 
faculties.  With  additional  notes  bv  an  American  editor.  One  volume,  12mo, 
379  pages,  muslin.     Price,  $1.25. 

lid   be   found   in  tin-  library  of  both  the  physician  and  the  naturalist." — New  Jersey 
ifedi  aX  and  Surgical  Reporter. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


19 


Physiology. 


Harris,  Vincent,  M.D., 


Member  of  the  Eoyal  College  of  Physicians  ;  Demonstrator  of  Physiology  at  St.  Bartholomew's  Hos- 
pital, etc.  ;  and 


Power,  D'Arcy,  M.A.,  Oxon., 


Member  of  the  Royal  College  of  Surgeons  ;  late  Assistant  Demonstrator  of  Physiology  at  St.  Bartholo- 
mew's Hospital. 


MANUAL  FOR  THE  PHYSIOLOGICAL  LABORATORY. 

pages,  forty  illustrations,  muslin.     Price,  $1.50. 


One  volume,  8vo,  214 


"The  present  little  volume,  although  of 
modest  pretensions  and  narrow  in  scope,  is  a 
reliable  guide-book  for  the  student  who  desires 
to  learn  something  of  the  rudiments  of  histo- 
logical methods  and  histo-chemistry." — Medi- 
cal Record,  September  3,  18S1. 

"  The  prominence  given  to  laboratory  work 
in  all  well-equipped  medical  schools  has  cre- 
ated a  demand  for  such  books  as  the  volume 
under  notice,  which  is  in  every  way  fitted  to 


serve  the  needs  of  any  who  may  desire,  through 
manipulative  study,  to  familiarize  themselves 
with  the  essentials  of  histology,  histo-chem- 
istry,  and  physiology." — Louisville  Medical 
Mm,  October  28,  1882. 

"  This  little  book  is  a  useful  aid  to  work  in 
the  physiological  laboratory.  Its  main  strength 
lies  in  the  directions  given  for  conducting  mi- 
croscopic examinations  of  tissues." — Phila- 
delphia Medical  Times,  October,  1881. 


Satterthwaite,  Thomas  E.,  M.D., 


President  of  the  New  York  Pathological  Society  ;  Pathologist  to  the  St.  Luke's  and  Presbyterian  Hospi- 
tals, etc. 

A  MANUAL  OF  HISTOLOGY.  Edited  and  Prepared  by  Thomas  E.  Satter- 
thwaite, M.D.,  of  New  York.  In  association  with  Drs.  Thomas  Dwight,  J.  Col- 
lins Warren,  William  F.  Whitney,  Clarence  I.  Blake,  and  C.  H.  Williams,  of 
Boston  ;  Dr.  J.  Henry  C.  Snnes,  of  Philadelphia  ;  Dr.  Benjamin  F.  Westbrook, 
of  Brooklyn ;  and  Drs.  Edmund  C.  Wendt,  Abraham  Mayer,  R.  W.  Amidon, 
A.  R.  Robinson,  W.  R.  Birdsall,  D.  Bryson  Delavan,  C.  L.  Dana,  and  W.  H. 
Porter,  of  New  York  City.  New  edition,  with  appendix.  In  one  handsome  8vo 
volume,  profusely  illustrated,  490  pages,  muslin.     P^ice,  $4.50. 


"  It  will  find  a  ready  welcome  from  all 
workers  in  this  department,  as  being  a  trust- 
worthy and  valuable  epitome  of  the  subject 
according  to  the  light  of  the  most  recent  in- 
vestigations, and  as  being  by  far  the  best 
English  text-book,  as  adapted  to  the  wants  of 
the  student  and  busy  practitioner  ;  as  such  we 
heartily  recommend  it." — American  Journal 
of  the  Medical  Sciences. 

"This  book  is  what  it  purports  to  be,  a 
manual  in  the  true  sense  of  the  word,  and  will 
meet  the  wants  of  the  busy  practitioner,  as 
well  as  the  student  who  is  just  commencing 
study  in  this  important  department." — Medi- 
cal Times. 

"We  commend  it  to  the  teachers  of  histol- 
ogy in  our  colleges  as  a  fitting  class-book  ;  one 
to  be  studied,  and  not  as  one  of  reference." — 
Therapeutic  Gazette. 

"  In  every  respect  it  is  a  book  that  we  can 
heartily  commend  to  all  who  desire  to  study 
this  most  attractive  and  useful  branch  of  medi- 
cine." — iVas7iville  Journal  of  Medicine  and 
Surgery. 

"Few  medical  works  on  any  subject  have 
had  the  advantage  of  such  a  galaxy  of  co- 
workers, and  no  subject  is  of  more  interest  or 


I  more  necessary  to  physicians  who  would  keep 
'  abreast  with  medical  progress.  The  work  is 
alike  creditable  to  the  editor — as  he  is  pleased 
to  call  himself — his  collaborators,  and  the 
I  medical  profession  in  the  United  States." — 
j  The  Sanitarian,  New  York  City. 

"We   would    recommend   the    'Manual    of 
Histology '  to  any  physician   or  student  who 
!  desires  to  be  proficient  in  the  medical  sciences." 
j  — Chicago  Medical  Journal  a?id  Examiner. 

"  This  is  really  a  superb  work,  and  will  be 

■  sought  for   by  those  engaged  in  histological 

work.     Such  a  work  as  this  should  be  studied 

i  in   conjunction  with  physiology,  whether  the 

student  is  able  to  follow  along  with  the  micro- 

t  scope  or  not." — Cincinnati  Medical  JVevjs. 

"  It  may  be  said  that  Satterthwaite's  '  Man- 

.  ual '  worthily  represents  the  histological  knowl- 

j  edge  of  to-day,  and  it  may  be  safely  used  as  a 

I  guide-book  by  students  and  practitioners." — 

Medical  Record. 

"The  appendix  contains  whatever  has  been 
recently  added  to  our  knowledge  of  the  lymph- 
atic system  and  the  salivary  glands.  Those 
who  have  toiled  through  the  histological  fogs 
of  some  other  work  willappreeciate  this  book. " 
—  Virginia  Medical  Monthly. 


Thudichum,  J.  L.  W.,  M.D., 

A  MANUAL  OF  CHEMICAL  PHYSIOLOGY,  Including  its  Points  of  Contact  with 
Pathology.     One  volume,  8vo,  195  pages,  muslin,  illustrated.     Price,  $2.25. 


'20 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


Physiology,  Pathology,  and  Therapeutics. 
Strieker,  Prof.  S., 

Of  Vienna,  Austria. 
A  MANUAL  OF  HISTOLOGY.  Written  in  co-operation  with  Th.  Meynert,  P. 
Von  Recklinghausen,  Max  Schultze,  W.  Waldeyer,  and  others.  Trans- 
lated by  Henry  Power,  of  London  ;  James  J.  Putnam  and  J.  Orne  Green. 
of  Boston  ;  Henry  C.  Eno,  Thomas  E.  Satterthwaite,  Edward  C.  Segtjin, 
Lrcrrs  D.  Bulkxey,  Edward  L.  Keyes,  and  Francis  E.  Delafield,  of 
Kew  York.  American  translation  edited  by  Albert  H.  Buck,  Assistant  Aural 
Surgeon  to  the  New  York  Eye  and  Ear  Infirmary.  One  volume,  imperial  8vo, 
1,106  pages,  four  hundred  and  thirty-one  illustrations.  Price,  muslin,  $9.00; 
leather,  $10.00. 


"At  once  the  most  extended  and  valuable 
treatise  on  Histology  which  has  yet  appeared." 
— American  Journal  of  the  Medical  Sciences. 

' '  The  translation  of  Mr.  Powers  covers  406 
pages  of  the  present  edition  ;  but  the  remain- 
ing articles  are  translated  by  the  American 
gentlemen  above  named.  Nearly  two-thirds, 
therefore,  of  the  book  are  translated  by  Amer- 
icans, who  are  physicians  especially  interested 
in  the  departments  which  they  have  under- 
taken. In  this  there  is  evident  advantage,  as 
one  who  is  already  familiar  with  a  subject  is 
the  more  likely  to  grasp  obscure  points,  which 
are  perhaps  rendered  still  more  obscure  by  be- 
ing couched  in  a  foreign  idiom.  There  is  also 
likely  to  be  more  freshness  about  an  article 
thus  translated  than  if  it  form,  in  the  original, 
one  of  a  large  number,  and  by  different  au- 
thors, translated  by  a  single  individual ;  for  the 
weariness  which  must  necessarily  grow  upon 
the  translator  of  so  large  a  volume,  is  not  re- 
lieved by  the  increasing  familiarity  which  he 
must  acquire  if  the  papers  are  all  by  the  same 
author. 

"  This  series  of  papers,  edited  and  in  many 
instances  written  by  Prof.  Strieker,  consti- 
tutes at  once  the  most  extended  and  most 
accurate  treatise  on  Histology  extant.  And 
as  the  stud}'  of  Histology  is  a  subject  which 
admits  only  the  latest  and  most  accurate  in- 
formation to  its  aid,  this  work  must  necessa- 
rily supersede  all  others.  It  becomes,  therefore, 
absolutely  indispensable  to  every  histologist 
and  physiologist  in  the  world,  as  well  as  to  all 

Griesinger,  "W.,  M.D., 


physicians  and  surgeons  who  would  pursue 
their  departments  with  all  the  light  of  modern 
science." — Philadelphia  Medical  Times. 

''  The  need  of  a  work  of  this  kind  has  been 
felt  for  some  time  past.  The  last  edition  of 
Kolliker  contains  points  which  he  himself  has 
altered  in  his  later  editions,  which  have  not 
been  translated.  The  publication  of  this  work 
is  destined  to  give  increased  zest  to  the  study 
of  minute  anatomy,  a  study  which  is  becom- 
ing a  necessity  to  any  one  who  desires  to  be  a 
thoroughly  educated  physician. 

"We  believe  this  book  to  be  indispensable 
to  any  physician  who  desires  to  understand 
the  present  position  of  medical  science,  and 
to  know,  if  not  to  find  out  for  himself,  the 
present  knowledge  of  the  minute  anatomy  of 
the  human  body.  The  authors,  as  remarked 
before,  are  men  who  have  devoted  themselves 
to  these  studies,  and  do  not  limit  themselves 
to  communication  of  the  facts,  but  in  many 
places  treat  of  the  methods  of  obtaining  good 
specimens  for  self-study. 

"As  for  the  book  itself,  it  has  been  pub- 
lished in  good  style.  The  type  is  clear,  the 
wood-cuts  are  equal  to  those  of  the  German 
edition,  and  there  are  but  few  typographical 
errors."' — The  Medical  Record. 

"  Every  medical  student  and  every  scientific 
practitioner  should  study  this  work,  as,  better 
than  any  other  in  the  English  language,  it  ex- 
hibits what  has  been  demonstrated  respecting 
the  minute  structure  of  the  body." — Detroit 
Review  of  Medicine. 


at  of  Clinical  Medicine  and  of  Medical  Science  in  the  University  of  Berlin  :  Honorary  Member  of 
the   Medico-Phyaiolotrical  Association;    Membre   Associe  Etranger  de  la  Societe  Medico-Pbysiolo* 
de  Pari*,  etc.,  etc. 

MENTAL  PATHdLOGY  AND  THERAPEUTICS.    Translated  from  the  German  by 
C.  LO(  kji\i:t  Robertson,  M.D.  Cantab.,  Medical  Superintendent  of  the  Sus- 
Lunatio  Asylum,   Hay  wards   Heath,  and  JAMES  RUTHERFORD,  M.D.,  Edin- 
burgh.    Sold  only  by  subscription.      See  page  54. 


Wood's  Pocket  Manuals. 

THE    PBESOEIBEE'S    MEMOEANDA. 
Price,  $1.00. 

me  of  the   compiler  of  this  little 
work  is  iot  given  on  the  title-page.     There  is 
face,  no  introduction,  and  no  claim  to 
led    la   want  long   felt.'      This  un- 
usual modesty  caused  ns  to  look  over  the  book 
OUghly,  anil  we  say  that  it  is  one 
o)  thi  a]  little  books  of  this  cbarac- 

rhich    lias  appeared." — Buffalo    Medical 
md  Surgical  Journal^  November,  1881. 


One  volume,  32mo,  300  pages,  muslin. 


"A  convenient  little  pocket  manual;  dis- 
eases and  accidents  arranged  in  alphabetical 
order,  and  favorite  prescriptions  of  well-known 
physicians  given  under  each  head." — Obstetric 
Oazette,  November,  1881. 

"  This  is  a  convenient  little  book  for  hasty 
reference." — Therapeutic  Gazette,  November, 
1881. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


21 


Microscopy. 


Brocklesby,  John,  A.M., 


Professor  of  Mathematics  and  Natural  Philosophy  in  Trinity  College,  Hartford. 

THE  AMATEUR  MICROSCOPIST  ;  or,  Views  of  the  Microscopic  World.  A  Hand- 
book of  Microscopic  Manipulation  and  Microscopic  Objects.  Illustrated  with 
two  hundred  and  forty-seven  figures  on  wood  and  stone.  One  volume,  8vo, 
144  pages,  muslin.     Price,  $1.75. 


"  A  little  book  full  of  curious  and  interest- 
ing facts  regarding  the  microscopic  world." — 
Our  Young  Folks. 

"Published  in  very  beautiful  shape." — 
Evening  Mail. 

'"  It  treats  of  the  microscope,  how  to  use  it, 
and  how  to  prepare  microscopic  objects  for 


examination.  .  .  .  There  are  about  two 
hundred  and  fifty  illustrations  beautifully  ex- 
ecuted. " — Illinois  Teacher. 

"  The  book  is  finely  gotten  up,  and  will  be 
found  useful  to  all  teachers  who  desire  to  ex- 
tend their  knowledge  into  this  most  interest- 
ing domain." — Kansas  City  Journal. 


Frey,  Heinrich, 

Professor  of  Medicine  in  the  University  of  Zurich. 

THE  MICROSCOPE  AND  MICROSCOPICAL  TECHNOLOGY.  A  Text-book  for 
Physicians  and  Students.  Translated  and  Edited  by  Geo.  R.  Cutter,  M.D. , 
Surgeon  New  York  Eye  and  Ear  Infirmary  ;  Ophthalmic  and  Aural  Surgeon  to 
the  St.  Catherine  and  Williamsburg  Hospitals,  etc. ,  etc.  Illustrated  by  three 
hundred  and  eighty-eight  engravings  on  wood.  One  volume,  Svo,  660  pages. 
Price,  muslin,  $6.00;  or  colored  leather,  $7.00. 


"In  many  respects  we  think  this  the  best 
work  on  the  microscope." — Detroit  Review  of 
Medicine. 

"  A  complete  exposition  of  the  subject, 
thoroughly  indispensable  to  the  practical 
mioroscopist. " — Chicago  Medical  Journal. 

"  The  work  is  presented  very  modestly,  yet 
we  find  it  not  only  very  accurate  in  all  its  de- 
tails of  process,  but  complete  as  regards  varie- 
ty of  topics  treated.  The  condensed  style  of 
the  author,  the  fairness  of  his  nature,  together 
with  his  understanding  of  histology,  permit 
an  unbiassed  discussion  of  nearly  all  questions 
of  microscopic  anatomy,  and  many  of  obscure 
pathology.  The  rules  for  testing  and  select- 
ing an  instrument  are  especially  valuable  to 
one  about  to  purchase." — New  York  Journal 
of  Medicine. 

"We  conceive  this  work,  of  all  others,  par- 
ticularly fitted  by  its  completeness  and  ar- 
rangement to  serve  the  student,  whether  be- 
ginner or  one  far  advanced.  The  best  and 
most  recent  methods  are  here  given  in  detail. 
The  additions  of  the  editor  make  this  part  of 
the  work  complete  to  the  present  time.  Each 
tissue  and  organ  is  treated  with  a  complete- 
ness limited  only  by  the  present  progress  of 
microscopic  art.  The  translator  and  editor 
deserves  the  gratitude  of  the  medical  profes- 
sion for  placing  before  an  English  reading 
public  Dr.   Frey's  work,  rendered  still  more 


valuable  by  his  own  judicious  brackets." — 
Broion-SequarcVs  Archives  of  Scientific  and 
Practical  Medicine. 

"  Those  who  are  familiar  with  Prey's  admi- 
rable manual  will  feel  grateful  to  Dr.  Cutter 
for  his  very  readable  translation,  which  ena- 
bles our  American  and  English  students  who 
are  unacquainted  with  the  German  tongue  to 
participate  in  the  instructions  of  the  renowned 
Zurich  professor.  These  directions  for  inves- 
tigation possess  an  especial  value  to  the  Amer- 
ican observer,  on  account  of  the  explicit 
manner  in  which  are  described  the  manifold 
improved  methods  of  demonstrating  the  vari- 
ous structures  in  their  healthy  or  diseased 
conditions.  To  sum  up  all,  we  think  that  this 
handsome  volume  is  one  which  the  working 
microscopist  cannot  afford  to  do  without. " — 
Philadelphia  Medical  Times. 

"We  advise  all  commencing  the  study  of 
microscopy  to  purchase  Frey  on  the  Micro- 
scope."— Buffalo  Medical  and  Surgical  Jour 
rial. 

"  It  is  a  pleasure,  indeed,  to  call  the  atten- 
tion of  the  profession  to  this  very  superior 
work  With  this  excellent  work  the  beginner 
and  the  expert  possess  all  that  can  be  desired 
for  the  prosecution  of  their  studies  and  inves- 
tigations."— Richmond  and  Louisville  Medical 
Journal, 


Carpenter,  Wm.  B,,  C.B.,  M.D.,  LL.D. 

THE  MICROSCOPE   AND  ITS  REVELATIONS.     Sixth  Edition.. 

Volume    I.  Illustrated  by  one  colored  and  twenty- six  plain  plates,  and  five  hun- 
dred and  two  fine  wood-engravings. 

Volume  II.  Illustrated  with   twenty-six  plates  and  five  hundred  and  two  fine 
wood-engravings.     Sold  only  by  subscription.     See  page  53. 


22 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


Foods,  Poisons,  Surgery. 


Pavy,  F.  W.,  M.D.,  F.S. 

A  TREATISE  ON  FOOD  AND  DIETETICS.     Second  Edition.     Sold  only  by  sub- 
scription.    See  page  55. 


Blyth,  A.  W.,  M.R.C.S. 


THE  ANALYSIS    OF  FOODS  AND  THE  DETECTION  OF  POISONS.      With  il- 
lustrations.    One  volume,  12mo,  463  pages,  muslin.     Price,  $1.00. 


''This  work  consists  of  two.  parts.  One 
devoted  to  the  Analysis  of  the  principal  arti- 
cles of  Diet  in  daily  use  ;  the  otiier  to  the 
Detection  and  Estimation  of  Poisons,  organic 
and  inorganic.  In  the  first  portion  the  author 
has  endeavored  to  give  a  clear  and  concise 
account  of  the  various  Foods  and  Beverages, 
with  the  best  and  most  recent  Methods  for 
the  Detection  of  any  Adulterations.  A  few 
of  the  more  important  legal  cases  are  detailed, 
where  their  bearing  on  the  subject  renders 
them  helpful ;  and  to  every  article  is  appended 
a  Bibliography  of  the  works  and  papers  con- 
sulted. 

In  the  Second  Portion,  the  arrangement  of 
the  Organic  Poisons  is  simply  that  which  sug- 
gests itself  naturally  into  methodical  investi- 
gation— the  more  volatile  Poisons,  those  that 


are  obtained  by  processes  of  distillation,  being 
considered  first ;  and  in  the  second  place, 
those  extracted  by  alcoholic  or  ethereal  sol- 
vents. The  Inorganic  Poison*,  finally,  are 
taken  in  the  order  in  which  they  may  most 
conveniently  be  sought." — Extract  from  Pref- 
ace. 

"Will  be  used  by  every  analyst." — The 
Lancet. 

"  A  work  full  of  great  interest  .  .  .  the 
method  of  treatment  excellent." — Westmiu-- 
ster  Review. 

"  Stands  unrivalled  for  completeness  of  in- 
formation. ...  A  really  practical  hand- 
book. " — Sanitary  Record. 

"  The  whole  work  is  full  of  useful  practical 
information. " — Chemical  News. 


Hamilton,  Frank  Hastings,  A.M.,  M.D.,  LL.B., 

Professor  of  the  Practice  of  Surgery,  with  Operations,  and  of  Clinical  Snrgery,  in  Bellevue  Hospital 
Medical  College  ;  Visiting  Surgeon  to  Bellevue  Hospital ;  Consulting  Surgeon  to  Bureau  of  Surgical 
and  Medical  Relief  for  the  Out-door  Poor,  at  Bel'evue  Hospital ;  to  the  Central  Dispensary  ;  and  to 
the  Hospital  for  the  Kuptured  and  Crippled ;   Fellow  of  the  New  York  Academy  of  Medicine,  etc. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.  Illustrated  with  four  hun- 
dred and  sixty-seven  engravings  on  wood.  One  volume,  royal  8vo,  954  pages. 
Price,  in  muslin,  $7.00,  or  in  leather,  $8.00. 


"Has  evidently  been  prepared  with  the 
greatest  care,  both  on  the  part  of  the  author 
and  his  publishers  ;  and  as  a  text-book  for  the 
student  it  reflects  the  highest  credit  upon  its 
well-known  and  gifted  writer.  As  a  text- 
book for  the  student,  or  one  of  reference  for 
the  busy  practitioner,  it  undoubtedly  is  one  of 
Che  beat  and  most  modern  that  has  yet  ap- 
peared."—  The  Medical  Record. 

"A  valuable  addition  to  our  list  of  text- 
books, an  excellent  work  of  reference,  a  credit 
to  our  professional  literature." — New  York 
.)/.  dical  Journal, 

"  It  will  be  found  an  excellent  and  common- 
nense  volume. " — London  Medical  I'imes  and 
■  tie. 


"This  is  one  of  the  best  text-books  upon 
surgery  which  we  have  ever  seen,  and  we  rec- 
ommend it  highly  to  the  profession." — Chicago 
Mi  dical  Examiner. 

"Professor  Hamilton's  latest  work  is  one 
that  will  add  to  his  already  high  reputation. 
.  .  .  It  is  full  of  valuable  practical  sug- 
gestions and  directions." — American  Journal 
of  the  Mednal  Sciences. 

"American  in  plan,  scientific  in  method, 
written  in  clear,  concise,  classical  English, 
Professor  Hamilton's  Surgery  is  a  noble  lega- 
cy to  the  medical  student,  an  honor  to  the 
profession,  and  an  ornament  to  our  native 
tongpe. " — Detroit  Review  of  Medicine. 


Keetley,  C.  B.,  F.R.C.S., 


K.-nior  Surgeon  to  the  West  London  Hospital ;   Surgeon  to  the  Surgical  Aid  Society. 

AX  INDEX  OF  SURGERY.  Being  a  Con,  is,.  Classification  of  the  Main  Facts  and 
Theories  <d'  Surgery,  for  the  Use  of  Senior  Students  and  others.  One  volume, 
8vo,  320  pages,  muslin.     Price,  $2.00. 

"Will   prove  truly   valuable,   and    will,    we  ;  alphabetical,  and  the  text  is  written  in  as  de- 
frost, for   many  years  be  kept  up  to  the  im-  |  gant  and   intelligible   English   as   can  be  ex- 
periotu   demands  of   surgical    progress.      The    pected  in  condensations  and    abridgments." — 
■patera  of  aarangement  is  just  what  the  system     British  Medical  Journal. 
in  such  a  publication  should  ever  be,  purely 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


23 


Surgery. 


Holmes'  System  of  Surgery. 


SYSTEM  OF  SURGERY,  THEORETICAL  AND  PRACTICAL,  IN  TREATISES 
OF  VARIOUS  AUTHORS.  Edited  by  T.  Holmes,  M.D. ,  Surgeon  and  Lecturer 
on  Surgery,  St.  George's  Hospital,  and  Surgeon-in-Chief  to  the  Metropolitan 
Police.  Third  Edition,  thoroughly  revised.  Three  volumes,  upward  of  3,000 
pages.  With  numerous  woodcuts,  lithographs,  and  chromo-lithographs.  Price, 
in  muslin,  $21.00  ;  in  leather,  $24.00  ;  in  half  morocco,  $27.00. 


"It  is  fully  up  to  the  times,  and  forms  a 
most  complete  work  on  the  theory  and  prac- 
tice of  surgery." — Therapeutic  Gazette. 

"  The  work  as  a  whole,  claiming  as  it  does 
to  represent  the  English  school  of  surgery,  is 
complete  in  every  respect,  and  really  stands 
without  a  rival.  As  it  stands,  it  represents 
the  original  and  latest  Holmes'  System  of  Sur- 
gery, and  contains  the  most  recent  views  of 
the  many  distinguished  authors  who  first  con- 
tributed to  its  pages." — The  Medical  Record. 


"Whatever  may  be  the  belief  in  the  influ- 
ence of  antisepsis,  in  whole  or  in  part,  every 
progressive  Surgeon  has  learned  the  value  of  the 
cardinal  principles  of  cleanliness,  local  disin- 
fection, and  free  drainage.  In  the  volume  be- 
fore us  these  principles  are  duly  considered, 
and  the  different  points  in  dispute  are  very 
judiciously  presented.  The  same  may  be  said 
regarding  other  subjects  of  equal  importance 
in  their  bearing  on  surgical  operation." — 
Medical  Record. 


Clarke,  W.  Fairlie,  M.A.  and  M.B.,  Oxon.,  F.H.C.S., 

Assistant  Surgeon  to  Charing  Cross  Hospital. 

A  MANUAL  OF  SURGERY.  A  new  edition,  thoroughly  revised,  with  important 
additions  by  an  American  surgeon.  Nearly  two  hundred  illustrations.  Over 
300  pages.     Sold  only  by  subscription.     See  page  57. 


Wyeth,  John  A.,  M.B.,  Univ.  of  Louisville, 


Member  of  the  New  York  County  Medical  Society ;   the  Np.w  York  Pathological  Society  ;    Honorary 
Member  of  the  College  of  Physicians  and  Surgeons  of  Little  Rock,  Arkansas. 


ESSAYS  IN  SURGICAL  ANATOMY  AND  SURGERY. 

pages,  illustrated,  muslin.     Price,  $2.00. 


One  volume,   8vo,   262 


A  HANDBOOK  OF  MEDICAL  AND   SURGICAL   REFERENCE. 
18mo,  279  pages,  muslin.     Price,  $1.25  ;  tucks,  $1.50. 


One    volume, 


Bauer,  Louis,  M.D.,  M.R.C.S.,  Eng., 


Professor  of  Anitomy  and  Clinical  Surgery  ;  Licentiate  of  the  New  York  State  Medical  Society ;  Mem- 
ber of  the  New  York  Pathological  Society,  of  the  American  Medical  Association ;  Corresponding 
Fellow  of  the  London  Medical  Society,  etc. 

LECTURES  ON  ORTHOPAEDIC  SURGERY.  Delivered  at  the  Brooklyn  Medical 
and  Surgical  Institute.  Revised  and  augmented.  One  volume,  8vo,  336  pages, 
illustrated,  muslin.     Price,  $3.25. 

''We  are  especially  pleased  with  the  chap- I  our  knowledge  admits   of." — Pacific  Medical 
ters  on  diseases  of  the  spine  and  joints  which  !  and  Surgical  Journal. 

occupy  a  large  portion  of  the  book.     Dr.  Bauer  |      "  As  a  treatise  on  deformities  we  have  very 
has  had  every  opportunity  of  acquainting  him-    few  works  to  compare  with  it,  so  thorough  and 
self  with  all  the  sources  of  information  on  the  i  exhaustive  has  the  author  made,  its  considera- 
subject,  and  his  work  will  be  found  as  nearly  j  tion." — St.  Louis  Medical  Reporter. 
complete  as  the  present  advanced  condition  of 


Carnochan,  John  Murray,  M.D., 


Lecturer  on  Operative  Surgery  with  Surgical  and  Pathological  Anatomy,  etc.,  etc. 

A  TREATISE  OF  THE  ETIOLOGY,  PATHOLOGY,  AND  TREATMENT  OF 
CONGENITAL  DISLOCATIONS  OF  THE  HEAD  OF  FEMUR.  Illustrated 
by  lithographed  plates.     One  volume,  8vo,  235  pages,  muslin.     Price,  $2.00. 

"  By  far  the  most  complete  and  systematic  I  "  We  feel  a  pride  that  the  first  monograph 
work  in  the  English  language,  and  the  only  i  on  this  subject  in  the  English  language  is  from 
one  which  contains  any  directions  for  treat-  j  the  pen  of  an  American,  and  that  it  is  credita- 
ment." — British- American  Medical  and  Phijs-  ,  ble  to  its  author." — American  Journal  of  the 
ical  Journal.  Medical  Sciences. 


24        PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Surgery. 
Poulet,  Alfred,  M.D., 

Adjutant  Surgeon  Major,  Inspector  of  the  School  for  Military  Medicine  at  Val-de-Grace. 

A  TREATISE  ON  FOREIGN  BODIES  IN  SURGICAL  PRACTICE.  Illustrated  by 
original  wood-engravings.  Translated  from  the  French.  Volumes  I.  and  II. 
Sold  only  by  subscription.     See  page  56. 

Taylor,  Charles  Fayette,  M.D., 

Surgeon  to  the  New  York  Orthopaedic  Dispensary  and  Hospital ;  Fellow  of  the  New  York  Academy  oi 
Medicine  ;  Member  of  the  New  York  County  Medical  Society,  and  Permanent  Member  of  the 
American  Medical  Association. 

ON   THE    MECHANICAL    TREATMENT    OF   DISEASE   OF  THE   HIP-JOINT. 

One  volume,  8vo,  62  pages,  illustrated,  muslin.     Price,  $1.25. 


Peugnet,  Eugene,  M.D., 


Surgeon  to  the  Northwestern  Dispensary  ;  Member  of  the  New  York  Pathological  Society,  of  the  Medi- 
co-Legal Society  of  the  City  of  New  York,  and  of  the  Medical  Society  of  the  County  of  New  York, 
etc.,  etc. 

THE  NATURE  OF  GUNSHOT  WOUNDS  OF  THE  ABDOMEN,  AND  THEIR 
TREATMENT  :  Based  on  a  Review  of  the  Case  of  the  late  James  Fisk,  Jr.,  in 
its  Medico-legal  Aspects.     One  volume,  Svo,  96  pages,  muslin.     Price,  $1.25. 

Pilcher,  Lewis  S.,  A.M.,  M.D., 

Of  Brooklyn,  N.  Y. 

THE  TREATMENT  OF  WOUNDS.  Being  a  Treatise  on  the  Principles  upon  which 
the  Treatment  of  Wounds  should  be  Founded,  and  on  the  Best  Methods  of  car- 
rying them  into  Practice,  including  a  Consideration  of  the  Modilications  which 
Special  Injuries  may  demand.     Illustrated  by  wood-engravings. 


Salter,  S.  James  A.,  M.B.,  F.R.S., 


Member  of  the  Royal  College  of  Surgeons  and  Examiner  in  Dental  Surgery  at  the  College  ;  Dental  Sur- 
geon to  Guy's  Hospital. 

DENTAL   PATHOLOGY  AND   SURGERY.     One  volume,   Svo,   399  pages,   illus- 
trated, muslin.     Price,  $4.50. 

"  Mr.  Salter  was  educated  as  a  surgeon,  and  I  long  been  known  as  one  of  the  most  scientific 
was  House  Surgeon  to  King's  College  Hospital,  |  dentists  of  the  day.  Mr.  Salter  had  the  great 
and  practised  surgery  for  the  first  few  years  |  advantages  of  such  a  complete  medical  educa- 
of  his  career  ;  hence  it  is  that  he  has  given  to  j  tion  as  is  implied  by  the  possession  of  a  de- 
tin-  profession  an  admirable  treatise,  not  only  j  gree  of  the  University  of  London,  upon  which 
on  the  pathology  of  the  teeth  but  also  on  den-  j  he  turned  his  attention  to  dental  subjects,  and 
tal  surgery.  ...  In  conclusion,  we  would  I  he  has  continued  his  labors  upon  the  broad  ba- 
recommend  the  book  as  a  most  able  and  prac-  sis  thus  laid  down,  with  the  satisfactory  re- 
tical  treatise  on  dental  surgery  and  pathology,  (suits  that  he  has  contributed  not  a  little  to 
It  tells  all  that  is  known  on  the  subject  in  a  both  the  science  and  practice  of  dentistry,  the 
id  pleasant  style,  and  should  be  read  by    latter  in  its  widest  sense.     .     .     .     We  close 


all  who  are  interested  in  that  special  depart- 
ment  of  Borgery.  The  book  is  well  printed, 
and  illustrated  with  one  hundred  and  thirty- 
three-  excellent  wood-engravings." — Medical 
'/'-///'.<  a  ad  Gazette. 
"This  handsome  volume  embodies  the  re- 
bi  i  and  experiences  of  a  surgeon  who  has 


Mr.  Salter's  work  well  satisfied  that  it  is  an 
honest  record  of  good  physiological  and  prac- 
tical work,  and  we  congratulate  both  the  sur- 
gical and  dental  professions  on  possessing  such 
a  valuable  work  of  reference." — London  Lan- 
cet. 


Goddard,  Paul  B.,  M.D.,  M.R.N.S.,  M.R.P.S., 

Demonstrator  of  Anatomy  in  the  University  of  Pennsylvania,  Lecturer  on  Anatomy,  etc.,  etc. 

THE  ANATOMY,  PHYSIOLOGY,  AND  PATHOLOGY  OF  THE  HUMAN  TEETH. 
With  the  .Most  Improved  Methods  of  Treatment,  including  Operations,  and  the 
Method  of  Making  and  Setting  Artificial  Teeth.  With  thirty  plates.  Aided  in 
the  practical  part  by  JOSEPH  E.  PARKER,  Dentist.  One  volume,  4to,  227  page?, 
muslin.     Price,  (8.75. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY.         25 


Surgery,  Diseases  of  Women. 


Owen,  Professor  Richard, 

THE  PRINCIPAL  FORMS  OF  THE  SKELETON  AND  THE  TEETH;  as  a  Basis 
for  a  System  of  Natural  History  and  Comparative  Anatomy.  One  volume,  12mo, 
304  pages,  illustrated,  cloth..     Price,  75c. 


The  International  Encyclopaedia  of  Surgery, 

A  Systematic  Treatise  on  the  Theory  and  Practice  of  Surgery.  By  authors  of 
various  nations.  Edited  by  John  Ashhurst,  Jk.  ,  M.D.,  Professor  of  Clinical 
Surgery  in  the  University  of  Pennsylvania.  In  six  volumes,  royal  8vo.  Illus- 
trated with  chromo-lithographs  and  wood-engravings.  Price  per  volume, 
muslin,  $6.00;  leather,  $7.00;  half  morocco,  $8.00.  Sold  only  by  subscrip- 
tion.    See  page  61. 

Munde,  Paul  F„  M.D., 

Professor  of  Gynecology  at  the  New  York  Polyclinic  and  at  Dartmouth  College ;  Gynecologist  to  Jit. 
Sinai  Hospital  :  Obstetric  Surgeon  to  Maternity  Hospital ;  Fellow  of  the  Obstetrical  Society  of  New 
Yoik,  and  of  the  American  Gynecological  Society,  etc.,  etc. 

A  TEXT-BOOK  OF  MINOR  SURGICAL  GYNECOLOGY.  One  volume,  8vo, 
nearly  600  pages,  illustrated  with  over  three  hundred  engravings,  bound  in  ex- 
tra muslin.     Price,  $5.00. 

E5gr°  Dr.  Munde's  Manual,  which  appeared  as  one  of  the  volumes  of  the  second  series  of 
Wood's  Library  of  Standard  Medical  Authors,  met  with  such  a  cordial  reception,  and  exten- 
sive sale,  that  the  publishers  arranged  with  the  distinguished  author  for  the  production  of  a 
didactic  work  which  would  be  based  upon  the  previous  one,  and  incorporate  all  its  best  feat- 
ures in  addition  to  such  other  matter  as  would  be  necessary  in  consequence  of  the  advance- 
ment of  the  science  and  the  requirements  of  a  book  suitable  for  teaching  purposes. 

The  work  here  announced  is  the  result,  and  the  publishers  confidently  expect  for  it  an  un- 
exampled popularity  in  its  field.  To  such  as  are  not  familiar  with  the  previous  work  the 
publishers  would  say,  hi  explanation  of  the  scope  and  character  of  this,  that  it  is  intended  to 
treat  of  those  minor  technicalities  and  manipulations  commonly  employed  in  the  diagnosis 
and  treatment  of  diseases  of  women.  As  the  scope  of  a  work  which  covers  the  whole  vast 
field  of  gynecological  science  does  not  permit  the  detailed  discussion  of  many  practical  points 
which  the  student  and  practitioner  should  know,  and  is  obliged  to  learn  with  many  annoy- 
ances in  the  course  of  his  practice,  this  work,  while  it  is  not  supposed  to  supply  the  knowledge 
gained  at  the  bedside  or  operating-table,  will  attempt  to  lay  before  the  reader  a  clear  and  con- 
cise description  of  details  and  manipulations,  the  ignorance  of,  or  want  of  experience  in  which 
will  often  lead  to  errors  both  of  omission  and  commission.  The  profuse  illustration  of  instru- 
ments and  operations  and  the  careful  details  in  description,  will  render  the  work  exceptionally 
vjluable  to  those  giving  especial  attention  to  the  treatment  of  diseases  of  women,  and  indis- 
pensable to  the  general  practitioner,  who  can  in  this  form  only  avail  himself  of  the  special- 
ists' experience. 

Duncan,  J.  Mathews,  A.M.,  M  D.,  etc., 

Lecturer  on  Midwifery  and  Diseises  of  Women  and  Children  in  Surgeons'  Hall  Medical  School ;  Clinical 
Lecturer  on  Diseases  of  Women  in  the  Royal  Infirmary  ;  Physician  to  the  Royal  Maternity  Hospi- 
tal ;  Honorary  Member  of  the  Obstetrical  Society  of  London  ;  of  the  Hunterian  Medical  Society ; 
of  the  Medical  Society  of  Norway  :  of  the  Gynaecological  Society  of  Boston ;  of  the  ObstetriGal  Soci- 
ety of  Louisville  ;  of  the  Imperial  Royal  Society  of  Physicians  of  Vienna ;  and  of  the  North  of  Eng- 
land Obstetrical  Society,  etc.,  etc. 

ON  THE  MORTALITY  OF  CHILDBED  AND   MATERNITY  HOSPITALS.     One 

volume,  8vo,  172  pages,  muslin.     Price,  $2.50. 

A  PRACTICAL  TREATISE  ON  PERIMETRITIS  AND  PARAMETRITIS.  One 
volume,  12mo,  249  pages,  muslin.     Price,  $2.50. 

"  Thorough  ability,  power  of  getting  to  the  I  Duncan's     former     publications."  —  Medical 
bottom  of  his  subjects,  acute  criticism,  and     Times  and  Gazette. 
careful  observation  mark  the  present,  as  Dr.  I 

Partridge,  Edward  L.;  M.D., 

New  York  City. 

THE  OBSTETRICAL  REMEMBRANCER.  A  neat  32mo  volume.  Profusely  illus- 
trated with  miniature  wood-engravings.  (Wood's  Pocket  Manuals.)  Price, 
$1.00. 


26        PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Diseases  of  Women. 
Sims,  J.  Marion,  A.B.,  M.D., 

Late  Surgeon  to  the  Woman's  Hospital.  New  York  ;  Fellow  of  the  New  York  Academy  of  Medicine  :  of 
the  New  York  Pathological  Society  ;  of  the  New  York  Historical  Society  ;  of  the  New  York  State 
Medical  Society;  of  the  Uoyal  Medical  and  Chirurgical  Society,  London;  of  the  London  Medical 
Society  ;  of  the  Pathological  Society  ;  Hon.  Fellow  of  the  Obstetrical  Society.  London  ;  Honorary 
Member  of  the  German  Society  of  Physicians  and  Naturalist?,  Paris  ;  Hon.  Fellow  of  the  Imperial 
Academy  of  Medicine  of  Belgium  ;  Knight  of  the  Legion  d"Honneur,  etc. 

CLINICAL  NOTES  ON  UTERINE  SURGERY.  With  Special  Reference  to  the 
Management  of  the  Sterile  Condition.  One  volume,  8vo,  4Ul  pages,  illustrated, 
paper.     Special  Edition.     Price,  $1.00. 

"He  is  original  in  conception,  persevering  every  practitioner,  young  and  old.     While  its 

under  difficulties,  logical  in  his  deduction,  and  teachings  are  so  simple  that  the  merest  tyro 

has,  above  all,  opened  the  way  to  the  develop-  can  fully  comprehend  them,  they  are  replete 

ment  of  a  subject  that  has  been  a  stumbling-  with  valuable  lessons  to  the  physician  of  ripe 

block  to  the  medical  profession.      We  com-  ,  experience.     We  have  perused  the  work  with 

mend  this  work  to   our  readers." — New   Or-  much  satisfaction,  arising  from  it  refreshed 

leans  Medical  and  Surgical  Journal.  rather  than  sated." — Pacific  Medical  and  Sur- 

"The  volume  should  be  in  the   hands  of  gical  Journal. 


Skene,  Alexander,  J.  C,  M.D., 


Professor  of  the  Diseases  of  Women  in  the  Long  Island  College  Hospital ;  Fellow  of  the  American  Gyne- 
cological Society  ;  Corresponding  Member  of  the  Gynecological  Society  of  the  County  of  Kings,  and 
of  the  Obstetrical  Society  of  New  York. 

DLSEASES    OF   THE    BLADDER  AND    URETHRA   IN  WOMEN.     One  volume, 
8vo,  374  pages,  illustrated,  muslin.     Price,  $3.00. 

"  In  addition  to  the  sterling  practical  matter  uDr.  Skene  has  rendered  the  profession  a 
in  which  this  work  abounds,  we  have  the  ad-  real  service,  while  the  meagre  information  on 
vantage  of  illustrations  admirably  executed,  this  subject  heretofore  within  the  reach  of 
particularly  in  the  chapter  on  urinary  analy-  busy  practitioners  will  command  for  this  book 
sis." — The  Canada  Lancet.  j  the  place  it  should  fill  in  every  library." — St. 

"  This  work  of  the  distinguished  gynecolo-  j  Louis  Medical  and  Surgical  Journal. 
gist  fills  a  vacancy  in  medical  literature.  It]  "  These  lectures  are  exactly  what  the  author 
may  be  declared  the  only  systematic  treatise  claims  for  them — a  convenient,  plain,  uncom- 
upon  the  subject  in  the  English  language,  and  plicated  statement  of  the  principal  diseases  of 
for  that  reason  its  advent  will  be  hailed  with  ,  the  female  urethra  and  bladder." — Detroit 
joy  by  the  profession  throughout  the  country."  :  Lancet. 
— Nashville  Journal  of  Medicine.  ' 


Bedford,  Gunning  S.,  A.M.,  M.D., 


Formerly  Professor  of  Obstetrics,  the  Diseases  of  Women  and  Children,  and  Clinical  Obstetrics,  in  the 
University  of  New  York;  author  of  "  Clinical  Lectures  on  the  Diseases  of  Women  and  Children." 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  Carefully  revised 
throughout  and  enlarged.  One  volume,  8vo,  703  pages,  illustrated  by  four 
colored  lithographic  plates  and  ninety-nine  wood-engravings.  Price,  muslin, 
$5.50;  leather,  $6.50. 


"  As  a  practical  guide  it  is  a  truly  excellent 
one — perhaps  in  1  his  respect  it  is  unsurpassed." 
Cflatgow  Medical  Journal. 


"  It  is  systematic  in  its  arrangement,  clear 
and  explicit  in  its  teachings."  —  American 
Journal  of  the  Medical  Sciences. 


CLINICAL   LECTURES    ON   THE    DISEASES    OF  WOMEN   AND   CHILDREN. 
One  volume,  8vo,  0(>7  pages.     Price,  muslin,  $4.00  ;  leather,  $5.00. 

"  Successful  as  the  work  has  been  at  home    guagee.      We   congratulate  the   author  upon 

and  abroad,  we  were  not  prepared   to  see  it    this  high  compliment  paid  to  his  labors  in  the 

achieve  a  success  exceedingly  rare  in  the  his-    still  new  field  of  uterine  pathology,  where  so 

tory  of  American   medical  authorship,  viz.,  a    many  struggle  vainly  for  reputation. " — Atner- 

tiion  into  the  French  and.  German  Ian-  ■  ican  Medical  Times. 

Garrigues,  Henry  Jacques,  A.M.,  M.D., 

Obstetric  Sturgeon  to  the  Maternity  jlospital  ;  Physician  to  the  Gynecologicnl  Department  of  tbe  Ger- 
man  Dispensary;  Fellow  of  the  American  Gynecological  Society;  Fellow  of  the  New  York  Obstet- 
rical  Bode)  I 

DIAGNOSIS  OF  OVARIAN  CYSTS  BY  MEANS    OF  THE   EXAMINATION    OF 

Til  Kill  CONTENTS.     One  volume,  «vo,  112  pages,  illustrated,  muslin.     Price, 
$1.26. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


av 


Diseases  of  Women. 


Verrier,  E.,  M.D. 

PRACTICAL  MANUAL  OF  OBSTETRICS.  Fourth  edition,  enlarged  and  revised, 
with  four  Obstetric  Tables  of  Professor  Pajot.  First  American  edition,  with  re- 
vision and  annotations  by  Edward  L.  Partridge,  M.D.,  Professor  of  Obstetrics 
in  the  New  York  Post-Graduate  Medical  School.  One  volume,  8vo,  420  pages, 
illustrated  by  one  hundred  and  five  wood-engravings.  Fine  muslin  binding. 
Sold  by  subscription  only.     See  page  52. 


Braun,  Dr.  Carl  R., 

Professor  of  Midwifery,  Vienna. 

THE  UREMIC  CONVULSIONS  OF  PREGNANCY,  PARTURITION,  AND 
CHILDBED.  Translated  from  the  German,  with  notes,  by  J.  Matthews  Dun- 
can, F.R.C.P.E.,  Lecturer  on  Midwifery,  etc.  One  volume,  12mo,  182  pages, 
muslin.     Price,  $1.00. 


lv  It  contains,  in  a  condensed  form,  the  most 
complete  and  reliable  history  of  this  affection 
yet  published." — New  York  Journal  of  Medi- 
cine. 

"We  advise  all  who  feel  interested  in  the 
subject  to  procure  it,  as  it  will  fully  repay  the 


perusal." — St.   Louis  Medical    and    Surgical 
Journal. 

"A  most  valuable  essay,  and  one  that 
will  not  be  easily  rivalled  for  its  completeness 
and  erudition." — Dublin  Medical  Press. 


Byford,  William  H.,  A.M.,  M.D., 


Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  Chicago  Medical  College,  etc.,  etc. ; 
author  of  ''The  Practice  of  Medicine  and  Surgery  applied  to  the  Diseases  and  Accidents  incident 
to  Women  ;  "   "  Chronic  Inflammation  of  the  Unimpregnated  Uterus,"  etc.,  etc. 

A  TREATISE  ON  THE  THEORY  AND  PRACTICE  OF  OBSTETRICS.  Illus- 
trated with  one  hundred  and  fifty  wood-engravings.  One  volume,  8vo,  469 
pages,  muslin.     Price,  $3.75. 

"  Professor  Byford  has  been  long  and  favor-  |  art  in  the  most  available  form.    It  is  complete, 
ably  known  to  the  professional  public  by  his    though  not  large ;  it  is  full  and  perfect,  and 


numerous  communications  to  the  medical 
press,  his  previously  published  elaborate  books, 
and  by  his  widely  extended  private  and  con- 
sultative practice.  .  .  .  Professor  Byford's 
book  is  fully  up  to  the  times,  and  a  successful 
exposition  of  the  subject." — Chicago  Medical 
Journal. 

"  Byford's  Obstetrics  affords  the  student  and 
practitioner    the  science  and  practice  of  the 


still  is  compressed  into  comparatively  small 
space.  It  contains  what  is  known,  and  com- 
mends itself  to  the  profession,  and  especially 
to  medical  students,  by  its  plain,  well-con- 
sidered, complete  teachings.  Everything  that 
can  be  said  in  favor  of  any  work  on  this  sub- 
ject can  be  said  of  it." — Buffalo  Medical  Jour- 
nal. 


Klob,  Julius  M.,  M.D., 

Professor  at  the  University  of  Vienna. 

PATHOLOGICAL  ANATOMY  OF  THE  FEMALE  SEXUAL  ORGANS.  Trans- 
lated from  the  German  by  Joseph  Kammerer,  M.D.,  Physician  to  the  German 
Hospital  and  Dispensary,  New  York  ;  and  Benjamin  F.  Dawson,  M.D.,  As- 
sistant to  the  Chair  of  Obstetrics  in  the  College  of  Physicians  and  Surgeons,  New 
York.     One  volume,  8vo,  299  pages,  muslin.     Price,  $3.50. 

Chapman,  Edwin  Nesbit,  M.D., 

Late  Professor  of  Obstetrics,  Diseases  of  Women  and   Children,  and  Clinical  Midwifery  in  the  Long 
Island  College  Hospital. 

HYSTEROLOGY  :  A  Treatise,  Descriptive  and  Clinical,  on  the  Diseases  and  the 
Displacements  of  the  Uterus.  Illustrated  with  superior  woodcuts.  One  volume, 
8vo,  504  pages,  muslin.     Price,  $4.50. 

"  His  book  is  well  worth  reading.  It  is  emi-  i  "  He  has  contributed  valuable  clinical  cases, 
nently  clinical." — London  Medical  Times  and  and  his  treatment  appears  satisfactory  in  most 
Gazette.  \  instances. '' — Buffalo  Med.  and  Surg.  Journal. 


28        PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Diseases  of  Women. 
Emmet,  Thomas  Addis,  M.D., 

Surgeon-in-Ch:ef  of  the  New  York  State  Woman's  Hospital,  etc.,  etc. 
VESICOVAGINAL   FISTULA  FROM    PARTURITION  AND    OTHER   CAUSES  ; 
with  Cases  of  Recto  vaginal  Fistula.     Illustrated  with  wood-engravings.     One 
volume,  8vo,  250  pages,  muslin.     Price,  $2.75. 

'■  A  careful  and  painstaking  record  of  many  '  "  No  work  of  its  size  has  so  much  enriched 
cases  of  vesico-vaginal  fistula,  arising  from  all  the  literature  of  gynecology  as  this  one." — 
sorts  of  causes.     The  operations  necessary  in    Medical  Record. 

each   case  are   clearly   described."  —  Medical]      "As   to  the  physique  of   the  book,  if  we 
Times  and  Gazette.  have  any  fault  to  find,  it  is  with  the  elegance 

"Certainly  no  one   is  more   competent   to    of  its  workmanship  and  costume,  in  which  re- 
give  an  opinion  in  the  matter  than  Dr.  Emmet,    spect  it  puts  to  blush  its  shelf- companions." — 
for  his  experience  has  been  great  indeed" —  ■  Pacific  Medical  and  Surgical  Journal. 
Cincinnati  Medical  Repertory. 

Brown,  W.  Symington,  M.D., 

Member  of  the  Gynaecological  Society  of  Boston  ;  Fellow  of  the  Massachusetts  Medical  Society,  etc. 
A  CLINICAL  HANDBOOK  ON  THE  DISEASES  OF  WOMEN.      Illustrated  with 
wood-engravings.     One  volume,  8vo,  247  pages,  muslin.     Price,  $2.50. 

"  The  author  writes  with  great  simplicity  |  a  master  of  his  subject,  and  chooses,  off-hand, 
of  diction,  his  style  much  resembling  that  of  a  the  shortest  route  to  the  understanding  of  his 
clear-headed  and  ready  clinical  lecturer  who  is  |  hearers." — Louisville  Medical  News. 

Tilt,  Edward  John,  M.D. 

A  HANDBOOK  OF  UTERINE  THERAPEUTICS  AND  DISEASES  OF  WOMEN. 
Fourth  Edition.     Sold  only  by  subscription.     See  page  55. 

Tait,  Lawson,  M.D. 

DISEASES  OF  WOMEN.  A  new  edition,  with  considerable  additions,  prepared  by 
the  Author  expressly  for  Wood's  Library.  This  very  compact,  \iseful  book  makes 
a  volume  of  204  pages,  with  illustrations.  Sold  only  by  subscription.  See 
page  57. 

Fritsch,  Heinrich,  M.D., 

Professor  of  Gynecology  and  Obstetrics  at  the  University  of  Halle. 
THE  DISEASES  OF  WOMEN.     A  Manual  for  Physicians  and  Students.      Trans- 
lated by  Isidore  Furst.     Illustrated   with   one   hundred  and  fifty  fine  wood- 
engravings.     Sold  only  by  subscription.     See  page  53. 

Savage,  Henry,  M.D., 

Fellow  of  the  Boyal  Colloge  of  Surgeons  of  England,  one  of  the  Consulting  Medical  Officers  of  the  Sa- 
maritan Hospital  for  Women. 

THE  SURGERY.  SURGICAL  PATHOLOGY,  AND  SURGICAL  ANATOMY  OF 
THE  FEMALE  PELVIC  ORGANS,  in  a  Series  of  Plates  taken  from  Nature, 
with  Commentaries,  Notes  and  Cases.  Third  Edition,  revised  and  greatly  ex- 
tended.    Sold  only  by  subscription.     See  page  56. 

Hart,  D.  Berry,  M.D., 

Lecturer  on  Midwifery  and  Diseases  of  Women,  School  of  Medicine,  Edinburgh,  etc.,  etc. ;  and 

Barbour,  A.  H.,  M.D., 

-tant  to  the  Professor  of  Midwifery,  University  of  Edinburgh. 
MANUAL  GE  GYNECOLOGY.     Volume  I.     Illustrated  with  eight  plates,  two  of 
which   are   in  colors,  and  one  hundred  and  ninety-two  fine  wood-engravings. 
Sold  only  by  subscription.     See  page  58. 

Volume  II.  Illustrated  with  a  lithographic  plate  and  two  hundred  and  nine  fine 
wood-engravings.     Sold  only  by  subscription.     See  page  53. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


29 


Diseases  of  Children,  etc. 


West,  Charles,  M.D. 


HOW  TO  NURSE  SICK  CHILDREN:  Intended  especially  as  a  Help  to  the  Nurses 
at  the  Hospital  for  Sick  Children  ;  but  containing  directions  that  may  be  found 
of  service  to  all  who  have  the  charge  of  the  young.  One  volume,  l8mo,  mus- 
lin.    Price,  50c. 


"  Should  be  in  the  hands  of  every  one  who 
has  charge  of   children." —  Western  Lancet. 


"It  is  beyond  value. " — Nelson's  American 
Lancet. 


Smith,  Eustace,  M.D., 


Fellow  of  the  Royal  College  of  Physicians  ;  Physician  to  his  Majesty  the  King  of  the  Belgians  ;  Physi- 
cian to  the  East  London  Children's  Hospital,  and  to  the  Victoria  Park  Hospital  for  Diseases  of  the 
Chest. 

A  PRACTICAL  TREATISE  ON  DISEASE  IN  CHILDREN. 
pages.     Price,  in  cloth,  $5.00;  in  leather,  $6.00. 


One  8vo  volume,  868 


"No medical  writer  has  written  so  well  upon 
the  wasting  diseases  of  children  as  Dr.  Smith. 
These  affections  are  exceedingly  common,  and 
often  baffle  the  best  efforts  of  the  physician. 

"In  preparing  a  fourth  edition  of  this  work 
for  the  press,  the  text  has  been  revised  and 
many  alterations  and  additions  have  been  in- 
troduced. Every  care,  however,  has  been 
taken  to  maintain  the  practical  character  of 
the  book,  so  that  it  may  continue  to  be  a  safe 
guide  to  the  management  of  some  of  the  com- 
monest, but  not  the   least   fatal,  maladies  of 


hance  its  practical  worth.  The  subjects  con- 
sidered are  : — Simple  Atrophy  from  Insuffi- 
cient Nourishment— Chronic  Diarrhoea,  Chron- 
ic Vomiting — Rickets — Inherited  Syphilis — 
Worms — Chronic  Pulmonary  Phthisis — Casea- 
tion of  Lymphatic  Glands — Diet  of  Children 
in  Health  and  Disease.  Some  reviewers  have 
criticised  the  chapter  on  diet  as  being  "too 
elaborate "  but  we  consider  it  not  elaborate 
but  complete." — Chicago  Medical  Times,  July, 
1S85. 

"The  author  is  a  clear,  concise  writer,  and 


early  life.  Every  physician  should  have  a  j  leaves  no  doubt  about  the  idea  he  intends  to 
copy  of  the  work  in  his  library." — The  Cincin-  '  convey.  One  of  the  most  valuable  chapters  in 
nati  Medical  News,  June,  1885.  I  the  book  is  that  upon  inherited  syphilis.    This 

"  Dealing  with  a  comprehensive   group   of    disease  is  so  prevalent,  and  especially  in  cities, 
diseases  characterized  by  wasting,  it  becomes    that  a  full  discussion  of  this  subject  is  at  all 


an  invaluable  aid  to  diagnosis  in  those  often 
obscure  cases.     It  is  especially  valuable  to  the 


times  valuable. 

"  Dr.  Smith  has  spoken  in  such  language  as 


practitioner  in  large  cities,  or  perhaps  we  might  |  to  leave  no  mistake  about  the  diagnosis  of  the 
more  truly  say  to  the  practitioner  wherever  he  J  disease,  and  this  is  a  point  which  cannot  be 
may  be  located,  who  has  to  deal  with  infant  overestimated,  as  the  difficulty  of  making  a 
constitutions  which  have  been  wrecked  by  city  diagnosis  of  the  disease  is  often  very  great, 
life.  The  book  is  full  of  subsidiary  informa-  ...  There  is  no  better  book  of  the  kind  in 
tion,  and,  dealing  as  it  does  with  diseases  the  English  language,  and  we  advise  our  friends 
characterized  largely  by  mal-nutrition,  con-  to  procure  it  at  once,  as  it  is  fully  abreast  of 
tains  the  most  carefully  elaborated  and  sue-  the  times  and  a  most  valuable  contribution  to 
cessfully  tested  systems  of  feeding." — The  a  library." — The  Medical  Herald,  Louisville, 
Therapeutic    Gazette,    Detroit,    Mich.,    July,    Ky.,  July,  18b5. 

1885.  "  The    great    importance    of    the    subject 

"  This  is  a  standard  work.     .     .     .     It  is    treated,  the  sound  judgment  exhibited  in  the 

the  book  to  which  the  author  owes,  in  a  large  ;  directions  as  to  treatment,  and  the  charming 

measure,  his  great  reputation  in  pediatric  medi-    style  of  writing,  render  it,  in  our  opinion,  the 


cine,  and  if  he  had  written  no  other,  would 
have  been  sufficient  to  support  his  fame.  .  .  . 
Each  section  of  the  work  is  developed  with  con- 
scientious attention  to  every  essential  detail, 
and  while  nothing  relative  to  the  pathology 
and  clinical  history  of  the  affections  named  is 
omitted,  the  great  question  of  constructive 
therapeutics  is  kept  ever  in  the  foreground, 
and  discussed  in  all  its  bearings  after  the 
manner  of  one  who  has  mastered  this  difficult 
problem  in  infantile  medicine." — Louisville 
Medical  News,  July  11,  1885. 


most  interesting  and  useful  book  of  the  kind 
that  has  ever  been  published." — The  Canadian 
Practitioner,  Toronto,  August,  1885. 

"The  chapters  devoted  to  nursing  and  diet 
are  exceptionally  rich  in  valuable  suggestions 
drawn  from  a  wide  and  intelligently  observ- 
ant experience." — The  Ncvj  England  Medical 
Gazette,  August.  1885. 

".  .  .  full  of  facts  pertaining  to  the  lat- 
est development  of  this  portion  of  medicine, 
all  expressed  in  the  language  of  a  master  of 
this  study  and  an  excellent  teacher.    The  por- 


"  This  edition  does  not  depart  from  the  tion  pertaining  to  infant  feeding  cannot  be 
practical  character  of  the  former  editions,  but  read  too  often  or  too  carefully." — Detroit  Lan- 
whatever  has  been  added  is  calculated  to  en-  '  cet,  August,  1885. 


Ellis,  Edward,  M.D. 

A  PRACTICAL  MANUAL  OF  THE  DISEASES  OF  CHILDREN,  with  a  Formu- 
lary. Third  Edition.  This  standard  book  makes  a  volume  of  225  pages.  Sold 
only  by  subscription.     See  p  ige  57. 


30         PUBLICATIONS  OF  WILLIAM  \YOOD  &  COMPANY. 
Diseases  of  Children,  of  the  Eye,  Anatomy. 


Henoch,  Dr.  Edward, 

Director  of  the  Clinic  and  Polyclinic  for  Diseases  of  Children  in  the  Royal  Charite  Hospital,  and  Pro- 
fessor in  the  Berlin  University. 

LECTURES  ON  DISEASES  OF  CHILDREN.  A  Handbook  for  Physicians  and 
Students.  Translated  from  the  German.  Sold  only  by  subscription.  See 
page  54. 

Routh,  C.  H.  F.,  M.D. 

INFANT  FEEDING,  AND  ITS  INFLUENCE  ON  LIFE  ;  or,  The  Causes  and  Pre- 
vention of  Infant  Mortality.  Third  Edition.  This  unique  work  forms  a  volume 
of  286  pages  in  Wood's  Library.     Sold  only  by  subscription.     See  page  57. 

Dwight,  Thomas,  A.M.,  M.D., 

Instructor  in  Topographical  Anatomy  and  Histology  in  Harvard  University  ;  Fellow  of  the  American 
Academy  of  Arts  and  Sciences ;  Snrgeon  at  the  Carney  Hospital. 

FROZEN  SECTIONS  OF  A  CHILD.  Fifteen  full-page  lithographic  plates,  draw- 
ings from  nature  by  H.  P.  Qdincy,  M.D.  One  volume,  royal  8vo,  66  pages, 
muslin.     Price,  $3.00. 

"  This  book  possesses  the  great  merit  nowa-  |  gans  are  no  longer  those  of  an  infant,  and  not 
days  i if  originality.  The  plates  are  pen  draw- I  yet  those  of  an  adult.  The  sections  from 
ings  from  sections  of  the  body  of  a  girl  said  to  which  these  drawings  are  made  begin  at  the 
be  three  years  old,  and  are  beautifully  and  neck,  and  continue,  about  and  inch  apart, 
graphically  executed.  They  possess  peculiar  through  the  trunk.  For  the  student  and  for 
attractions  to  the  anatomist  from  the  fact,  :  the  practitioner  this  book  will  prove  interest- 
stated  in  the  preface,  that  at  three  years  of  ing  and  practically  useful." 
age  the  proportions  of  the  body  and  of  the  or-  j 

Mauthner,  Ludwig, 

Royal  Professor  of  the  University  of  Vienna. 

THE  SYMPATHETIC  DISEASES  OF  THE  EYE.  Translated  from  the  German 
by  Warren  Webster,  M.D.,  Surgeon  United  States  Army,  and  James  A. 
Spauldixo,  M.D.,  Member  of  the  American  Ophthalmological  Society  ; 
Ophthalmic  Surgeon  to  the  Maine  General  Hospital.  One  volume,  12mo,  220 
pages,  muslin.     Price,  $2.00. 

"In  eo  far  as  regards  the  subject  of  this  reliable  description  of  the  multiform  symp- 

monograph,  we  may  truly  say  that  it  is  one  of  toms,    and     the    treatment    of    sympathetic 

the  most  important  with  which  the  oculist  is  ophthalmia,  so  that  they  may  at  once  recog- 

i  vex  I'oncerneA     Upon  his  correct  judgment  nize  its  presence,  and  treat  it  from  the  outset 

will  generally  depend  the  future  vision  of  the  appropriately  and  effectually.    Although  cases 

patient.     Much  more  orgeat,  therefore,  must  of  this  nature  are  comparatively  rare,   their 

-ity   for  general  practitioners  in  importance  is  sufficiently  great  to  account  for 

the  country,  and  for  medical  officers  of  the  the  appearance  of  this  excellent  work  in  an 

army  and  navy,  to  have  at  hand  a  clear  and  English  version." 


Noyes,  Henry  D.,  M.D., 


Profe    or  of  Ophthalmology  and  Otology  in  Bellevuc  Hospital  Medical  College ;  Surgeon  to  the  New 
Fork  Bye  and  Bar  Infirmary,  i 

DISEASES  OF  THE  EYE.     Illustrated  by  two  chromo-lithographs  and  numerous 
>  l-<'Ogravings.     Sold  only  by  subscription.     See  page  55. 

I        This  treatise  will  be  written  with  a  special  view  to  the  needs  of  the  general  practi- 
tioner, and  treats  the  subject  in  a  very  plain,  practical  way. 


Foote,  John,  M.D., 


Surgeons  In  London  ;  Corresponding  Member  of  the  Pharmaceutical 
and  formerly  Surgeon  to  the  Cholera  Hospital  at  St.  Ilelier's,  Jersey. 

OPHTHALMIC  MEMORANDA  :  RESPECTING  THOSE  DISEASES  OF  THE  EYE 
WHICH  AIM-;  MORE  FREQUENTLY  MET  WITH  IN  PRACTICE.  One  vol- 
ume, 18mo,  135  pages,  muslin.     Price,  50  cents. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


31 


Diseases  of  the  Eye. 


Stellwag  (von  Carion),  Dr.  Carl, 


Professor  of  Ophthalmology  in  the  Imperial  Royal  University  of  Vienna. 

TREATISE  ON  THE  DISEASES  OF  THE  EYE,  INCLUDING  THE  ANATOMY 
OF  THE  ORGAN.  Translated  from  the  fourth  German  edition,  and  edited  by 
D.  B.  St.  John  Roosa,  M.D.,  Clinical  Professor  of  the  Diseases  of  the  Eye  and 
Ear  in  the  University  of  the  City  of  New  York  ;  Surgeon  to  the  Manhattan  Eye 
and  Ear  Hospital ;  Charles  S.  Bull,  M.  D.,  formerly  Assistant  Surgeon  to  the 
Manhattan  Eye  and  Ear  Hospital  ;  Clinical  Assistant  in  the  New  York  Eye  and 
Ear  Infirmary,  etc.  ;  and  Charles  E.  Hackley,  M.D.,  Clinical  Professor  of  the 
Diseases  of  the  Eye  and  Ear  in  the  Woman's  Medical  College  of  the  New  York 
Infirmary  ;  Surgeon  to  the  New  York  Eye  and  Ear  Infirmary.  One  volume, 
imperial  8vo,  915  pages,  illustrated  by  wood-engravings  and  chromo-lithographs. 
Price,  muslin,  $5.00  ;  leather,  $6.00. 


"  It  should  be  in  the  hands  of  every  medical 
man,  and  no  one  can  safely  practise  ophthal- 
mology who  does  not  regard  the  subject  from 
a  standpoint  at  least  as  high  as  Stellwag  occu- 
pies."— New  York  Medical  Journal. 

"  This  is  one  of  those  complete,  exhaustive, 
magnificent  monographs  which  we  may  look 
for  in  vain  outside  of  Germany.  All  that 
modern  science  has  lent  to  the  diagnosis,  all 
that  the  most  careful  observation  has  con- 
tributed to  the  treatment,  and  all  that  the 
most  patient  research  has  furnished  to  the 
pathology  of  diseases  of  the  eye,  are  gathered 
together  in  this  comprehensive  volume." — 
Philadelphia  Medical  and  Surgical  Heporter. 

'*'  We  must  reluctantly  content  ourselves 
with  a  simple  indorsement  of  this  book,  as 
the  most  complete  and  trustworthy  compen- 
dium of  ophthalmology  that  has  been  offered 
to  American  physicians  since  the  appearance, 
many  years  ago,  of  the  great,  but  now,  in 
many  respects,  obsolete  works  of  Mackenzie 
and  Lawrence." — St.  Louis  Medical  and  Sur- 
gical Journal. 

"'  Of  the  work,  as  a  whole,  it  is  scarcely 
necessary  that  we  should  speak.  A  third 
edition  of  a  book  of  such  magnitude  means  in 
Germany  very  much  what  it  would  mean  in 
England,    that  the    ordeal   of   criticism   had 


been  passed  successfully  ;  and  the  translators 
are  fully  justified  in  calling  it  '  a  text-book 
which  is  regarded  as  one  of  the  best  in  the 
German  language.'  It  deals  fully  and  accu- 
rately with  every  branch  of  the  subject  to 
which  it  relates." — London  Lancet. 

"The  rapid  advance,  by  the  united  laborsv 
of  Graefe,  Helmholtz,  Donders,  Stellwag,  and 
others,  the  science  has  made  in  the  last  six- 
teen years,  very  naturally  led  us  to  look  to 
Germany  for  the  first  appearance  of  a  system- 
atic treatise  which  should  embody  the  pres- 
ent'advanced  stage  ot  ophthalmic  medicine 
and  surgery.  Prof.  Stellwag  has  furnished  us 
with  such  a  treatise.  It  is  a  library  in  itself, 
and  should  be  in  the  hands  of  every  man." — 
Detroit  Review  of  Medicine  and  Pharmacy. 

"  It  is  indeed  a  great  work,  and  will  take  its 
place  as  a  standard  authority  in  every  medical 
library." — Pacific  Medical  and  Surgical  Jour- 
nal. 

"  We  have  no  hesitation  in  saying  that  this 
work,  as  a  whole,  is  far  the  best  which  has  yet 
appeared  in  English ;  and  as  a  book  of  refer- 
ence for  the  consultation  of  authority  in  mat- 
ters pertaining  to  the  eye,  is  probably  without 
its  superior,  even  if  it  has  its  equal  in  any  lan- 
guage."— American  Journal  of  the  Medical 
Sciences. 


Roosa,  D.  B.  St.  John,  M.D.,  and  Ely,  Edward  T.,  M.D. 

OPHTHALMIC  AND   OTIC  MEMORANDA.     One  volume,  18mo,  298  pages,  mus- 
lin.    Price,  $1.00.     (Wood's  Pocket  Manuals.) 


"  It  must  prove  an  extremely  useful  work  to 
general  practitioners,  containing,  as  it  does, 
the  cream  of  the  subject." — Clinic. 

"This  small  book,  though  containing  only 
280  pag»'S,  gives  most  of  the  important  points 
in  both  ophthalmology  and  otology.  Its  style 
is  very  concise,  though  not  devoid  of  clear- 
ness."— Lancet  and  Observer. 


"Asa  concise  treatise  on  the  diseases  of  the 
eye  and  ear,  the  '  Memorandum '  is  all  that 
could  be  desired.  It  fulfils  all  that  its  authors 
promise."—  Western  Lancet. 

"We  have  rarely  seen  so  small  a  book  em- 
bracing so  much." — Philadelphia  Medical 
Times. 


Knapp,  H.,  M.D., 

Late  Professor  of  Ophthalmology,  and  Surgeon  to  the  Ophthalmic  Hospital  in  Heidelberg. 

A  TREATISE  ON  INTRAOCULAR  TUMORS.  FROM  ORIGINAL  CLINICAL  OB- 
SERVATIONS AND  ANATOMICAL  INVESTIGATIONS.  With  one  chromo- 
lithographic  and  fifteen  lithographic  plates,  containing  very  many  figures. 
Translated  by  S.  Cole,  M.D.,  of  Chicago.  One  volume,  octavo,  323  pages, 
muslin.     Price,  $3.75. 


32         PUBLICATIONS  OF  WILLIAM  WOOD  A  COMPANY. 

Diseases  of  the  Eye  and  Ear. 


De  Wecker,  L.,  M.D., 


Trofessor  of  Clinical  Ophthalmology,  Paris. 
OCULAR    THERAPEUTICS.     Translated  and  Edited  by  Litton  Forbes,  M.A., 
M.D.,   F.R.G.S. ,   Late  Clinical  Assistant  Royal  London  Ophthalmic  Hospital. 
One  volume,  8vo,  552  pages,  illustrated,  muslin.     Price,  $4.00. 

"Dr.  De  Wecker  has  written  a  very  in-  I  undoubted  genius  of  the  author,  his  great 
teresting  volume,  and  Dr.  Litton  Forbes  has  operative  skill,  his  vast  experience,  and  the 
done  good  service  in  rendering  it  into  excel-  many  advances  in  the  treatment  of  eye  affec- 
lent  English.  At  whatever  page  it  is  opened  ;  tions  which  have  undoubtedly  had  their  source 
the  reader  will  find  something  to  interest  him  i  in  the  originality  and  inventive  power  of  Dr. 
— something  novel,  or  some  new  application  of  !  De  Wecker.  Coming  from  such  a  pen,  care- 
old  knowledge.  In  their  chatty  and  agreeable  ;  fully  revised  and  condensed,  these  lectures 
style  these  lectures  remind  us  strongly  of  those  will  be  read  with  avidity  by  all  workers  in  this 
of  Trousseau." — The  Lancet.  j  branch  of  surgery,  and  hence  it  is  not  a  matter 

4 '  We  do  not  exaggerate  the  importance  of  i  for  surprise  that  already  they  have  been  trans- 
this  work  when  we  assert  that  it  marks  an  era  lated  into  Italian  and  Spanish,  and  are  about 
in  opbthalmological  science.  The  rapid  ad-  to  be  issued  in  Germany." — Dublin  Journal 
vauce  in  this  special  field,  especially  on  the    of  Medical  Sciences. 

Continent,  within  the  past  few  years,  renders  "  Here  we  have  the  fruits  of  an  exceptionally 
the  appearance  of  this  translation  of  Dr.  ;  large  experience,  and  the  matured  judgment  of 
Forbes  peculiarly  opportune  ;  and  this  is  one  one  who  has  contributed  largely  to  the  recent 
of  the  peculiar  attractions  of  this  work,  that  advances  made  in  this  branch  of  medicine." — 
it  is  written  with  a  terseness  and  perspicuity  Glasgow  Medical  Journal. 
which  render  it  easy  of  comprehension  to  the  "  We  do  not  know  that  we  ever  read  a  work 
general  practitioner,  while  it  must  prove  of    on  any  suhject  with  greater  pleasure  or  more 


equal  utility  to  the  special  worker,  dealing  as 
it  does  with  many  of  the  questions  of  practical 
interest  which  have  agitated  the  minds  of  oph- 
thalmic surgeons  for  some  time  past ;  and  this 
value  is  heightened  when  we  remember  the 

Buck,  Albert  H.,  M.D., 


profit.  It  is  a  splendid  rhume  of  modern  oph- 
thalmological  science.  It  sheds  still  greater 
lustre  on  the  name  of  its  illustrious  author, 
while  it  reflects  the  greatest  credit  on  the  able 
translator." — Dublin  Medical  Journal. 


Instructor  in  Otology  in  the  College  of  Physicians  and  Surgeon?,  New  York ,  Aural  Surgeon  to  the 
New  York  Eye  and  Ear  Infirmary  ;  Editor  of  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine  ; 
Editor  of  Reference  Handbook  of  the  Medical  Sciences  ;  and  Editor  of  "  A  Treatise  on  Hvgiene  and 
Public  Health.-' 


DIAGNOSIS  AND  TREATMENT   OF  DISEASES   OF  THE  EAR. 
subscription.     See  page  56. 


Sold  onlv  bv 


Allen,  Peter,  M.D., 


Fellow  of  the  Royal  College  of  Surgeons,  England  :  Aural  Surgeon  to  and  Lecturer  on  Aural  Surgery  at 
St.  Mary's  Hospital  ;  Aural  Surgeon  to  the  Royal  Society  of  Musicians;  Late  Surgeon  to  the  Metro- 
politan Ear  Infirmary,  Sackville  Street. 

LECTURES  ON  AURAL  CATARRH ;  OR,  THE  COMMONEST  FORMS  OF  DEAF- 
NESS AND  THEIR  CURE.  (Mostly  delivered  at  St.  Mary's  Hospital.)  One 
volume,  12mo,  277  pages,  illustrated,  muslin.     Price,  $2.00. 


"  Full  of  valuable  information  for  the  gen- 
eral practitioner.  We  find  here  an  explanation 
of  manv  conditions  which  are  often  overlooked 
or  misinterpreted  by  others  than  those  who  de- 
mote themselves  to  the  specialty  of  aural  dis- 
American  Journal  of  Insanity. 

"  It  forms  one  of  the  most  reliable  manuals 
Aural  Catarrh  that  can  be  placed  in  the 
hands  of  the  practitioner.  ...  It  will  be  of 
immense  service  to  the  general  practitioner, 
enabling  him  to  treat  the  most  ordinary  cases 
of  deafness  with  confidence,  and  to  prevent 
the  more  serious  ones  from  attaining  that  con- 


dition which  eventually  renders  them  insus- 
ceptible of  amelioration,  even  by  the  most  in- 
telligently directed  efforts.  It  is  a  work,  then, 
admirably  adapted  to  the  requirements  of  gen- 
eral practice,  and  one  which  we  especially 
recommend  to  the  student  in  otology  and  to 
the  busy  practitioner." — The  Medical  Iiecord. 
"  Aural  Catarrh  in  all  its  various  forms,  and 
in  its  complications  with  the  throat,  is  treated 
of  in  a  manner  at  once  interesting  and  satis- 
factory. It  is  quite  up  to  the  improvements 
of  the  present  day." — Cincinnati  Lancet. 


Helmholtz,  H., 

Professor  of  Physiology  In  the  University  of  Berlin,  Prussia. 
THi:   MECHANISM  OF  THE  OSSICLES  OF  THE  EAR  AND  MEMBRANA  TYM- 
I'A  NT.    Translated  from  the  German,  with  the  Author's  Permission,  by  Albert 
II    in  ik  and  NOBHAND  Smith,  of  New  York.     One  volume,  octavo,  69  pages, 
illustrated,  muslin.     Price,  $1.25. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


35 


Diseases  of  the  Ear,  Throat  and  Nose. 


Roosa,  D.  B.  St.  John,  M.D., 


Professor  of  Diseases  of  the  Eye  and  Ear  in  the  University  of  the  City  of  New  York  ;  Surgeon  to  the  Man- 
hattan Eye  and  Ear  Hospital ;  Consulting  Surgeon  to  the  Brooklyn  Eye  and  Ear  Hospital ;  formerly 
President  of  the  Medical  Society  of  the  State  of  New  York;  Corresponding  Member  of  the  Medico- 
Chirurgical  Society  of  Edinburgh  ;  Member  of  the  Medical  Society  of  the  County  of  New  York,  etc. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  THE  EAR,  INCLUDING 
THE  ANATOMY  OF  THE  ORGAN.  Sixth  Edition.  One  volume,  8vo,  740 
pages.  Illustrated  by  140  wood-engravings  and  chromo-lithographs.  Price, 
muslin,  $5.50;  leather,  $6.50. 


"If  any  one  has  the  right  to  speak  authori- 
tatively upon  otological  matters,  it  is  Dr. 
Roosa,  for  it  is  he  who,  more  than  any  one 
else,  has  made  known  to  the  American  medi- 
cal profession  the  general  principles  of  treat- 
ment of  aural  diseases  ;  and  it  is  safe  to  say 
that  no  book  upon  any  special  subject  has 
been  more  widely  distributed  throughout  the 
country  than  has  his  admirable  treatise.  If 
this  work  be  carefully  studied,  it  will  be  seen 
that  two  main  ideas  run  through  the  whole  of 
what  has  been  written  ;    first,  that  a  skilful 


treatment  of  ear-troubles  involves  a  consum- 
mate knowledge  of  general  medicine  ;  second, 
that  the  measure  of  success  is  determined  by 
the  thoroughness  which  the  practitioner  brings 
to  the  examination  of  his  cases,  before  apply- 
ing his  simple  armamentarium. 

"It  is  carefully  inculcated  that  nothing  is 
to  be  done  without  a  knowledge  of  what  is  re- 
quired, and  that  practice  '  in  the  dark '  (tenta- 
tive practice)  is  less  justifiable  in  this  branch 
of  medicine  than  in  any  other." — The  Medical 
Record. 


Bosworth,  Franke  Huntington,  M.D., 

Lecturer  on  Diseases  of  the  Throat  in  the  Bellevue  Hospital  Medical  College,  and  Physician  in  Charge 
of  the  Clinic  for  Diseases  of  the  Throat  in  the  Out-Door  Department  of  Bellevue  Hospital :  Fel- 
low of  the  New  York  Academy  of  Medicine,  of  the  American  Laryngological  Association,  and  Mem- 
ber of  the  Medical  Society  of  the  County  of  New  York. 

A  MANUAL  OF  DISEASES  OF  THE  THROAT  AND  NOSE.     One  volume,  octavo, 
448  pages.     Illustrated  with,  wood-engravings.     Muslin.     Price,  $3.25. 

"The  author  has  done  his  work  well,  and  in  j  "A  work  On  this  subject,  intended  more 
clear  and  expressive  language  gives  the  result  especially  for  the  general  practitioner  than  the 
of  his  by  no  means  small  experience.  .  .  ,    The  i  specialist,   is  what  is  wanted,   and  Dr.  Bos- 


work,  like  most  emanating  from  the  other  side 
of  the  Atlantic,  is  well  gotten  up,  paper,  type, 
and  woodcuts  being  excellent." — Edinburgh 
Medical  Journal. 

"  The  book  is  an  excellent  specimen  of  book 
making,  and  Dr.  Bosworth  has  honored  him- 
self and  the  profession  by  writing  it." — The 
American  Practitioner. 

"  The  author  gives  us  a  book  as  instructive 
as  it  is  interesting,  not  alone  to  the  specialist, 
but  to  the  general  practitioner  as  well." — St. 
Louis  Clinical  Record. 


worth  has  been  fortunate  in  the  manner  in 
which  he  has  approached  the  subject.  His 
handling  of  it,  moreover,  has  been  both  able 
and  judicious — a  statement  which  an  examina- 
tion of  the  book  is  sufficient  to  substantiate." 
— Michigan  Medical  News. 

1 '  There  are  a  thousand  excellent  hints  in 
this  volume,  which  is  an  eminently  practical! 
manual,  equally  creditable  to  author  and  pub- 
lisher, well  illustrated,  altogether  a  work  to 
be  recommended  to  both  student  and  practi- 
tioner."—  The  Canada  Lancet. 


Van  Troeltsche,  A. 

DISEASES  OF  THE  EAR  IN  CHILDREN. 


Price,  $1.50. 


Salter,  Henry  Hyde,  M.D., 


Fellow  of  the  Royal  College  of  Physicians;   Physician  to  Charing  Cross  Hospital,  and  Lecturer  on  the 
Principles  and  Practice  of  Medicine,  at  the  Charing  Cross  Hospital  Medical  School. 

ON  ASTHMA  :    ITS  PATHOLOGY  AND  TREATMENT.     Sold  only  by  subscription. 
See  page  54. 


See,  Germain, 


Member  of  the  Faculty  of  Medicine;    Member  of  the  Academy  of  Medicine;  Physician  to  the  Hotel 
Dieu.  etc.,  Paris. 

DISEASES  OF  THE  LUNGS,  OF  A  SPECIFIC,  NON-TUBERCULOUS  NATURE. 

Acute  Bronchitis,  Infectious  Pneumonia,  Gangrene,  Syphilis,  Cancer,  and  Hy- 
datids of  the  Lungs.  Translated  by  E.  P.  Hurd,  M.D.,  Member  of  the  Massa- 
chusetts Medical  Society ;  Vice-President  of  the  Essex  North  District  Medical 
Society  ;  One  of  the  Physicians  to  the  Anna  Jaques  Hospital,  Newburyport, 
Mass.  With  an  Appendix  by  the  Translator  on  the  German  Theory  of  Disease, 
and  on  the  Tubercle  Bacillus.  Sold  by  subscription  only.  See  page  51. 
$W  One  of  the  most  valuable  works  on  the  subject  of  recent  times,  fully  up  to  date. 
3 


34         PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Diseases  of  the  Xas-al  Cavities,  Larynx,  etc. 
Semeleder,  Dr.  Friedrich, 

Physician  in  Ordinary  to  his  Majesty,  the  Emperor  of  Mexico  ;  Member  of  the  Royal  Medical  Society  of 
Vienna  and  of  the  Medical  Society  of  Pantheon  in  Paris  ;  Formerly  Member  of  the  Medical  Faculty 
of  the  University  of  Vienna,  and  Surgeon  to  the  Branch  Hospital  at  Gumpendorf. 

RHINOSCOPY  AND  LARYNGOSCOPY  ;  THEIR  VALUE  IN  PRACTICAL  MEDI- 
CINE.    Translated  from  the  German  by  Edward  T.  Caswell,  M.D.     With 
woodcuts  and  two  chronio-lithographic  plates.     One  volume,  octavo,  191  pages, 
muslin.     Price,  $3.25. 
.   .   .    "  In  a  somewhat  careful  reading  of  this    of  the  professional  public  to  whom  it  comes." 
book,  we  have  found  much  that  is  of  practical   — New  York  Medical  Journal. 
value,  and  we  believe  this  will  be  the  verdict  I 

Mackenzie,  Morell,  M.D.,  London. 

DISEASES  OF  THE  PHARYNX,  LARYNX,  AND  TRACHEA.  Illustrated  by  112 
fine  wood-engravings.     Sold  only  by  subscription.     See  page  56. 

Robinson,  Beverley,  A.M.,  M.D.  (Paris), 

Lecturer  upon  Clinical  Medicine  at  the  Bellevue  Hospital  Medical  College,  New  York;  Physician  to  St. 
Luke's  and  Charity  Hospitals,  etc. 

A  PRACTICAL  TREATISE  ON  NASAL  CATARRH.  One  volume,  8vo,  illus- 
trated    Price,  muslin,  §2.50. 

"Among  the  man)- recent  contributions  to  "The    author    presents,    in  good   readable 

the  literature  of  the  above  subject  this  seems  style,    his   opinions   as   to   the   diagnosis   and 

to  be  superior  to  them  all." — Southern  Clinic,  treatment  of  this  stubborn  and  disheartening 

"The  book  is  well  written,  concise,  clear,  disease.     Aside  from  the  more  distinctly  pro- 

and    freely    illustrated." —  Chicago    Medical  fessional  suggestions,  he  gives  excellent  com- 

X'  W8.  mon-sense   advice   in   regard  to   matters    not 

"Its  teachings  are  mainly  original,   but  a  usually  dwelt  upon  in  treatises  on  disease  of 

free  comparison  of  the  methods  of  other  au-  the  nasal  cavity. " — American  Specialist. 
thors  are  discussed  in  relation  to  treatment, 
etc." — Arkansas  Medical  Monthly. 

James,  Prosser,  M.D. 

LARYNGOSCOPY  AND  RHINOSCOPY  IN  DIAGNOSIS  AND  TREATMENT  OF 
DISEASES  OF  THE  THROAT  AND  NOSE.  Fourth  edition,  enlarged,  one 
volume,  8vo,  223  pages.  Illustrated  with  wood-engravings,  and  five  hand-col- 
oivd  plates,  muslin.     Price,  $2.25. 

Jacobi,  A.,  M.D., 

Clinical  Professor  of  Diseases  of  Children  in  the  Collru'.-  of  Physicians  and  Surgeons.  New  York  ;  Phy- 
sician to  Bellevne,  Mount  Sinai,  and  the  German  Hospitals,  etc. 

A  TREATISE  ON  DIPHTHERIA.  One  volume,  octavo,  252  pages,  muslin.  Trice, 
$2.00. 

"  We  regard  Dr.  Jacobi's  work  as  one  of  the  to  thoroughly  appreciate  it,  it  should  be  read, 
most  valuable  which  has  recently  appeared  on  For  this  reason,  we  commend  it  to  the  profes- 
the  subject."  -Michigan  Medical  hew*.  sion,  and  we  guarantee  no  one  will  be  disap- 

"The  subject  is  handled  by  a  master,  and    pointed." — Therapeutic  Gazette. 

Ross,  James,  M.D., 

Hetnbex  of  the  Royal  College  <■!  Physicians,  London;  Assistant  Physician  to  the  Manchester  Royal 
[nflrmary;  <  aysiclan  to  the  Manchester  Southern  Hospital. 

A  TEE  \TI-i:  ON  THE  DISEASES.  OP  THE  NERVOUS  SYSTEM.    Second  Edition, 

d  and  enlarged.     Illustrated  with   Lithographs,  photographs,  and  three 

hundred  and  thirty-two  w leuts.  Two  volumes,  8 vo,  1,044  and  1,057  pages, 

muslin.     Price,  $15.00. 

"A    full  and  accurate  account  of  the  Bub-  and  not  a  mere  clinical  digest.     It  is  an  en - 

bowing    the   author's   mastery   of    the  cyclopaedia  of  facts  and  of  references  to  the 

whole   domain    of    nervous    maladies. " — The  literature  oi  France,  Germany,  England,  and 

Medical  Net  America.     This   work   may   be  considered   a 

"Indeed,    it   is   a  great   treasure-house   of  mirror  of  the  most  authentic  literature  of  this 

sta,  and  one  which  would  be  department."—  New  York  Medical  Journal. 

a   positivi    addition    to   any   library.       As   a  "  It  may  be  alleged  that  the  student  of  ner- 

work  of  reference  it  is  very  valuable."—  OaiU  vous  diseases  will  nowhere  else  find  all  the 

:/,  dical  Journal.  facts  brought  together  in  a  form  so  convenient 

La  that  of  a  history  or  an  essay,  and  serviceable." — The  Medical  News. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


35 


Diseases  of  the  Nervous  System. 


Rosenthal,  M.,  M.D., 

Professor  of  Diseases  of  the  Nervous  System  at  Vienna. 

A  CLINICAL  TREATISE  ON  THE  DISEASES  OF  THE  NEEVOUS  SYSTEM. 
With  a  Preface  by  Professor  Charcot.  Translated  from  the  Author's  Revised 
and  Enlarged  Edition  by  L.  Putzel,  M.D.,  Visiting  Physician  for  Nervous 
Diseases,  Randall's  Island  Hospital  ;  Physician  to  the  Class  for  Nervous  Dis- 
eases, Bellevue  Hospital  Out-door  Department,  and  Pathologist  to  the  Lunatic 
Asylum,  Black  well's  Island.  Illustrated.  One  volume,  8vo,  555  pages,  muslin. 
Price,  $5.50. 


"  For  a  treatise  on  diseases  of  the  nervous 
system,  there  is  no  work  better  arranged  or 
more  scientifically  executed.  The  author  is 
identified  with  the  more  advanced  discoveries 
and  researches  in  this  most  difficult  field  of 
medical  science,  and  we  may  safely  assert  that 
no  other  book  will  give  more  benefit  or  infor- 
mation on  nervous  diseases." — Atlanta  Medi- 
cal and  Surgical  Journal. 

"  Among  the  merits  of  this  book  worthy  of 
special  mention  are  its  uniformity  of  plan  and 
S3rstematic  divisions  and  subdivisions ;  the 
well-chosen  amount  of  space  and  attention 
which  are  devoted  to  each  disease,  the  careful 
presentation  of  the  subject  of  symptomatology, 
diagnosis,  and  prognosis,  and  the  numerous 
concise  reports  of  original  pathological  and  his- 
tological observations." — Philadelphia  Medi- 
cal Times. 

"  The  book  has  many  merits,  and  much  to 
commend  it  to  the  attention  of  the  profession. 
This  is  especially  true  in  regard  to  the  classi- 
fication,  thedescription  of  many  diseases,  and, 
on  the  whole,  in  regard  to  treatment." — Ar- 
chives of  Medicine. 

"  It  is  systematically  arranged,  and  is  writ- 
ten in  a  style  that  is  plain,  clear,  and  forci- 
ble ;  is  devoid  of  hypothetical  speculations, 
and  startling  and  remarkable  cures." — The 
Missouri  Dental  Journal. 


"The  great  advances  that  have  been  made 
in  the  diagnosis,  pathology,  and  treatment  of 
nervous  diseases  of  late  years,  have  been  noted 
in  this  treatise,  and  we  cheerfully  commend 
the  book  to  the  profession." — Southern  Clinic. 

' '  The  work  is  one  which  neurologists  will 
scan  with  interest." — Medical  and  Surgical 
Reporter. 

"  This  work  of  Rosenthal's  has  been  a  stand- 
ard on  the  diseases  of  the  nervous  system  in 
Germany  and  Austria  for  a  number  of  years, 
having  gone  through  several  editions.  It  has 
been  translated  into  French,  and  received  the 
commendations  of  French  Neuro-pathologists, 
especially  Professor  Charcot,  who  is  the  au- 
thor of  a  preface  to  the  American  translation. 
The  work  is,  as  it  purports  to  be,  a  clinical 
one,  being  especially  full  in  the  practical  de- 
partments of  symptomatology  and  treatment. 
The  pathological  descriptions  are  also  made 
prominent,  and  axe  unusually  clear.  The  data 
furnished  by  clinical  observations  and  patho- 
logical anatomy  are  explained  as  far  as  possi- 
ble by  physiology,  but  Dr.  Rosenthal  devotes 
very  little  space  to  theories  regarding  physio- 
logical mechanism,  differing  in  this  respect 
from  most  recent  writers  on  nervous  dis- 
eases."—  Toledo  Medical  and  Surgical  Jour- 
nal. 


Beard,  George  M.,  A.M.,  M.D., 


Fellow  of  the  New  York  Academy  of  Medicine,  of  the  New  York  Academy  of  Sciences  ;  Vice-President 
of  the  American  Academy  of  Medicine;  Member  of  the  American  Neurological  Association,  of  the 
American  Medical  Association,  the  New  York  Neurological  Society,  etc. 

A  PRACTICAL  TREATISE  ON  NERVOUS  EXHAUSTION  (NEURASTHENIA^, 
ITS  SYMPTOMS,  NATURE,  SEQUENCES,  TREATMENT.  New  Edition. 
One  volume,  8vo,  198  pages,  muslin.     Price,  $1.75. 


"  The  book  is  written  in  the  author's  usual 
lucid  style,  and  exhibits  the  results  of  original 
research  in  a  most  interesting  department  of 
medicine.  The  medical  world  owes  to  Dr. 
Beard  its  warmest  admiration  for  the  really 
good  work  which  he  has  done  in  this  special 
investigation,  made  in  the  neutral  space  be- 
tween clear  physiological  and  pathological 
condition. " — Medical  Record. 

"Dr.  Beard  has,  more  than  any  other  writer 
of  the  day,  contributed  to  establish  the  fact 
that  grave  appearance  of  local  disease  may 
exist  without,  in  fact,  having  a  local  organic 
habitation,  or  requires  a  name  dissevered  from 
the  general  nervous  system." — Alienist  and 
Neurologist. 

"The  merit  incontestably  belongs  to  Dr. 
Beard,  of  having  proved,  on  a  scientific  basis, 
the  existence  of  neurasthenia,  and  having  de- 
fined the  difference  between  this  form  of  ner- 
vousness and  that  which  is  the  expression  of 


organic  changes  in  the  various  departments  of 
the  nervous  system.  We  can  most  urgently 
recommend  to  all  physicians,  and  to  nervous 
specialists,  in  particular,  the  work  here  briefly 
reviewed  as  the  result  of  abundant  practical 
experience,  and  of  sharp  critical  observation." 
— Allgemeine  Wiener  Mcdiz.  Zeitung. 

"The  book  is  full  of  original  research  and 
observation,  and  all  the  points  as  to  symp- 
toms, etiology,  and  treatment,  are  amply  il- 
lustrated by  cases  which  have  come  under  the 
author's  own  observation." — Canada  Medical 
and  Surgical  Journal. 

"The  present  work  treats  of  the  diseased 
condition  which  has,  in  the  last  decades,  be- 
come so  disseminated,  not  only  in  America, 
but  also  with  us,  in  Germany,  that  every  prac- 
titioner encounters  it  on  his  rounds,  several 
times  daily." — From  the  Preface  of  the  Ger- 
man Translator. 


30 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


Diseases  of  the  Nerves,  Apoplexy. 


Gowers,  W.  R.,  M.D., 


Assistant  1'rofessor  of  Clinical  Medicine  in  University  College  ;  Senior  Assistant  Physician  to  Univer- 
sity College  Hospital  ;   Physician  to  the  National  Hospital  for  the  Paralyzed  and  Epileptic. 

EPILEPSY  AND  OTHER  CHRONIC  CONVULSIVE  DISEASES.      Their   Causes, 
Symptoms,  and  Treatment.     Sold  by  subscription  only.     See  page  51. 


DIAGNOSIS  OF  THE  DISEASES  OF  THE  BRAIN  AND  SPINAL  CORD, 
by  subscription  only.     See  page  51. 


Sold 


Bramwell,  B., 

DISEASES  OF  THE  SPINAL  CORD. 


Price,  $5.00. 


Putzel,  L.,  M.D., 


Visiting  Physician  for  Nervous  Diseases,  Randall's  Island  Hospital  ;  Physician  to  the  Class  for  Nervous 
Diseases.  Bellevue  Hospital  Out-door  Department ;  and  Pathologist  to  the  Lunatic  Asylum,  Black- 
weirs  Island. 

A  TREATISE  ON  COMMON  FORMS  OF  FUNCTIONAL  NERVOUS  DISEASES. 
Sold  only  by  subscription.     See  page  56. 


Lidell,  John  A.,  A.M.,  M.D. 

A  TREATISE  ON  APOPLEXY,  CEREBRAL  HEMORRHAGE,  CEREBRAL  EM- 
BOLISM, CEREBRAL  GOUT,  CEREBRAL  RHEUMATISM,  AND  EPIDEMIC 
CEREBRO -SPINAL  MENINGITIS.  One  volume,  8vo,  395  pages,  muslin. 
Price,  $4.00. 


"To  all  friends  of  ours  who  are  engaged  in 
the  study  or  treatment  of  cerebral  diseases,  we 
cordially  commend  this  work  as  the  most  com- 
plete and  satisfactory  of  any  that  we  have 
seen.  The  mechanical  execution  of  the  work 
is  excellent." — Detroit  Review. 


"  We  think  the  modest  hope  of  the  author, 
as  expressed  in  the  preface  to  this  excellent 
monograph,  that  it  will  prove  interesting  and 
useful  to  those  who  read  it,  will  be  fully  real- 
ized. .  .  .  We  heartily  recommend  the  work 
of  Dr.  Lidell  to  the  profession  as  one  of  very 
great  value. ,: — Philadelphia  Medical  Times. 

Erichsen,  John  Eric,  F.R.S., 

Surgeon  Extraordinary  to  the  Queen :  Emeritus  Professor  of  Clinical  Surgery  in  University  College, 
and  Consulting  Surgeon  to  the  Hospital :  Ex-President  of  the  Royal  College  of  Surgeons  of  Eng- 
land, and  of  the  Royal  Medical  and  Chirargical  Society,  etc. 

ON  CONCUSSION  OF  THE  SPINE,  NERVOUS  SHOCK,  AND  OTHER  OB- 
SCURE INJURIES  OF  THE  NERVOUS  SYSTEM  IN  THEIR  CLINICAL 
AND  MEDICO-LEGAL  ASPECTS.  One  volume,  12mo,  344  pages,  muslin. 
Price,  $2.25. 

The  distinguished  author  in  his  preface  ex-  i  railway  collisions,  they  were  not  peculiar  to 
plains  the  origin  of  this  hook,  as  having  been  them,  but  might  be  the  consequence  of  any  of 
six  lectures  on  certain  obscure  injuries  of  the  the  more  ordinary  accidents  of  civil  life.  As 
nervous  system  commonly  met  with  as  the  re-  :  the  work  is  now  presented,  it  includes  eight 
suit  of  shocks  to  the  body,  received  in  colli-  additional  lectures  and  has  been  expanded  in 
hions  on  railways,  His  objects  in  the  publica-  scope  to  embrace  a  wider  range  of  subjects. 
turn  were  to  direct  the  attention  of  surgeons  In  view  of  the  medico-legal  aspects  of  this 
to  a  class  of  injuries  that  had  hitherto  been  large,  obscure,  and  important  class  of  injuries 
I.  it  little  Doted;  to  endeavor  to  throw  some  of  the  nervous  system,  this  work  is  highly 
light  on  their  true  characters;  and,  lastly,  to  valuable, 
show  that  though   they  commonly  arose   from 

Eichet,  Chas.,  A.M.,  M.D.,  Ph.D., 

Former  Interne  of  the  Bospita]  of  Paris, 
PHYSIOLOGY    AND    HISTOLOGY    OF    THE   CEREBRAL   CONVOLUTIONS; 
ALSO,  POISONS  OF  THE  INTELLECT.     Translated  by  Edward  P.  Fowler, 
.Ml).     One  volume,  8vo,  170  pages,  illustrated,  muslin.     Price,  $1.50. 

"This  is  a  wry  thorough  and  eomprehen-  I  ebral  convolutions  goes,   and   more  attention 
siv«  treatise  on  the  subject  of  which  it  treats,    than    usual   is   given   to   their    structure." — 
thorough  and  complete  as  fara>  the  knowledge    Michigan  Medical  News. 
of  the  arrangement  and  morphology  of  the  cer- 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


37 


Diseases  of  the  Brain,  Idiocy,  etc. 


Benedikt,  Moriz, 

Professor  at  Vienna. 

ANATOMICAL  STUDIES  UPON  BRAINS  OP  CRIMINALS.  A  CONTRIBUTION 
TO  ANTHROPOLOGY,  MEDICINE,  JURISPRUDENCE,  AND.  PSYCHOL- 
OGY. Translated  from  the  German  by  E.  P.  Fowler,  M.D.,  New  York  ;  De- 
partment of  Translation,  New  York  Medico-Chirurgical  Society.  Illustrated 
with  wood-engravings.     One  volume,  8vo,  185  pages,  muslin.     Price,  $1.50. 

'  It  is  strictly  scientific  philanthropy,  and    lack  of  the  sentiment  of  wrong,  though  with 

a  clear  perception  of  it,  constitute  the  two 
principal  psychological  characteristics  of  a 
class  to  which  belongs  more  than  one-half  of 
condemned  criminals. 

"He  shows  deficiencies  in  the  cerebral  con- 
stitution of  criminals,  viz.  :  deficient  gyrus 
development,  and  a  consequent  excess  of  fis- 
sures, which  are  fundamental  defects.  These 
defects  are  evident  throughout  the  entire 
extent  of  the  brain.  The  work  is  of  great 
value." — Western  Medical  Reporter. 


reaches  to  the  scope  of  true  humanizing, 
Comprehending  as  it  does  the  psychology  of 
our  existence,  it  lays  hold  on  facts  most  per- 
tinent to  the  welfare  of  society,  individually 
and  collectively.  In  fact,  it  opens  up  a  very 
broad  and  entirely  neglected  source  of  infinite 
study,  and  should  awaken  new  research  into 
mental  phenomena. 

"  Dr.  Benedikt  is  of  opinion  that  an  inabil- 
ity to  restrain  themselves  from  the  repetition 
of  a  crime,  notwithstanding  the  full  apprecia- 
tion of  the  superior  power  of  the  law,  and  a 


Charcot,  J.  M., 


Professor  in  the  Faculty  of  Medicine  of  Paris  ;  Chief  of  the  Salpetriere  Hospital ;  Member  of  the  Aca- 
domie  de  Medecine,  of  the  Clinical  Society  of  London;  President  of  the  Societe  Anatomique  ;  for- 
mer Vice-President  of  the  Societe  de  Biologie,  etc.,  etc. 

LECTURES  ON  LOCALIZATION  IN  DISEASE*S  OP  THE  BRAIN.  Delivered  at 
the  Faculte  de  Medecine,  Paris,  1875.  Edited  by  Botjrneville.  Translated 
by  Edward  P.  Fowler,  M.D. ,  New  York.  Illustrated  with  forty-five  fine 
wood-engravings.     One  volume,  8vo,  133  pages,  muslin.     Price,  $1.50. 

"  We  heartily  commend  the  book  to  all  stu-  i  a  model  both  of  scrupulous  exactitude  in  ren- 
dents  of  nerve  disorders.  In  these  lectures  the  ;  dition  of  the  original  meaning,  and  as  a  clear 
matter  is  considered  in  the  direction  pointed  j  andunexceptional  style  of  English." — Ameri- 
out  by  normal  anatomy  and  experimental  phys-    can  Journal  of  the  Medical  Sciences 


iology.  But  as  supplementary  to  this,  there 
is  added  clinical  and  pathological  research." — 
Detroit  Lancet. 

"Issued  in  excellent  style,  and  with  illus- 
trations so  good  that  he  may  run  that  reads 
the  lessons  which  they  teach.     Dr.  Fowler's 


translation  is  endorsed  by  Charcot  himself  as    Medical  Record, 


"  Anything  from  the  pen  or  lips  of  M.  Char- 
cot is  at  once  treasured  by  the  profession. 
This  author  has  labored  so  assiduously  in  the 
field  of  cerebral  localization,  both  alone  and  in 
collaboration  with  M.  Pitres  and  others,  that 
he  is  in   a  position  to  speak  ex  cathedra.'1'' — 


Hamilton,  Allan  McLane,  M.D., 


One  of  the  Consulting  Physicians  to  the  Insane  Asylums  of  New  York  City,  and  the  Hudson  River 
State  Hospital  for  the  Insane. 

TYPES  OF  INSANITY.     AN  ILLUSTRATED  GUIDE  IN  THE  PHYSICAL  DIAG- 
NOSIS OF  MENTAL  DISEASE.     Price,  $2.50. 

£2F"  A  collection  of  ten  large  plates  from  photographs  of  selected  cases,  with  description, 
text,  and  an  appendix,  which  will  contain  directions  for  the  examination  and  commitment  of 
patients.  This  work  is  a  very  fine  series  of  studies,  beautifully  made,  mounted  on  tinted 
hoard,  and  inclosed  in  a  portfolio  envelope. 


Seguin,  Edward,  M.D. 

IDIOCY  AND  ITS  TREATMENT  BY  THE  PHYSIOLOGICAL  METHOD.     One 

volume,  8vo,*457  pages,  muslin.     Price,  $5.00. 

"This  work  is  well  worth  the  perusal  and 


"  Twenty  years  ago,  Dr.  Seguin  published 
fn  Paris  a  treatise  on  the  treatment  of  idiots, 
which  has  since  been  the  best  work  of  author- 
ity on  the  subject.  He  has  now  published  an- 
other work  on  idiocy,  embodying  in  it  our 
present  knowledge  of  the  malady,  expounding 
the  physiological  method  of  educating  idiots, 
and  setting  forth  rules  of  practical  treatment ; 


study  of  those,  and  they  are  many,  who  have 
never  given  the  subject  a  thought.  To  what 
extent  physiological  and  moral  treatment  can 
go  in  improving  the  condition  of  the  idiot  is 
here  shown,  and  we  think  it  is  a  source  of  in- 
finite delight  to  watch  the  progress  from  mere 
animal  life  to  almost  the  intelligent  being 


and  finally,  pointing  out  the  direction  to  be  I  has  been  here    shown  in  this   treatise." — St. 
given   to  future   scientific   effort." — London    Louis  Medical  Journal. 
Lancet.  \ 


.">>         PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


Diseases  of  the  Urinary  Organs. 


Bartholow,  R.,  A.M.,  M.D. 

SPERMATORRHOEA  :    Its  Causes,  Symptoms,  Results,  and  Treatment.      One   vol- 
ume, 8vo,  l'J8  pages,  illustrated,  ruuslin.     Price,  $1.25. 


Harrison,  Reginald,  F.R.C.S., 


Surgeon  to  the  Liverpool  Royal  Infirmary.     Formerly  Lecturer  on  Anatomy  and  Surpery  at  the  School 
of  Medicine,  and  Surgeon  to  the  Liverpool  Northern  Hospital. 

LECTURES  OX  THE  SURGICAL  DISORDERS  OF  THE  URINARY  ORGANS. 
Delivered  at  the  Liverrjool  Royal  Infirmary.  One  volume,  8vo,  399  pages, 
illustrated  with  lithographs  and  wood-engravings,  muslin.     Price,  $4.25. 

"This  edition  of  Mr.  Harrison's  lectures  orders  of  the  bladder  are  quite  fully  treated 
has  been  considerably  enlarged.  The  work  of  in  the  latter  half  of  the  book,  and  L-r.  Bige- 
treats  of  stricture  and  the  various  methods  of  low's  operation,  litholapaxy,  favorably  corn- 
treating  it,  the  author  taking  exception  to  Dr.  mented  on.  Injuries  and  surgery  of  the  kid- 
Otis'  method  upon  retention  of  urine,  injuries  ,  neys  are  considered  in  Chapters  25  and  '.'.G. 
to  the  urethra,  perineal  fistuke,  etc.     The  dis-  |  The  work  concludes  with  a  full  index." 

Coulson,  W.  J.,  F.R.C.S. 

OX  THE  DISEASES  OF  THE  BLADDER  AXD  PROSTATE  GLAXD.  Sixth 
edition,  revised.  One  volume,  8vo,  393  pages,  handsomely  illustrated.  Sold 
by  subscription  only.     See  page  55. 

Neubauer,  C,  M.D., 

Professor,  Chief  of  the  Agricultural-Chemical  Laboratory,  and   Docent  in  the  Chemical  Laboratory  in 
Wiesbaden ;  and 

Vogel,  J.,  M.D., 

Professor  of  Medicine  in  the  University  of  Halle. 

A  GUIDE  TO  THE  QUALITATIVE  AXD  QUANTITATIVE  AXALTSIS  OF  THE 
URIXE.  Designed  for  Physicians,  Chemists,  and  Pharmacists.  With  a 
Preface  by  Professor  Dr.  R.  FPvESENlUS.  Translated  from  the  seventh  enlarged 
and  revised  German  Edition  by  Elbridge  G.  Cutler,  M.D.,  Physician  to 
Out-Patients  of  the  Massachusetts  General  Hospital,  Pathologist  at  the  Boston 
City  Hospital,  and  Assistant  in  Pathology  in  the  Medical  School  of  Harvard 
University.  Revised  by  Edward  S.  Wood,  M.D.,  Professor  of  Chemistry  in 
the  Medical  School  of  Harvard  University.  In  one  superb  8vo  volume.  551 
pages.  Profusely  illustrated  with  engravings  and  four  fine  chromo-lithographic 
plates.     Pri.-e,  muslin,  $6.00;   leather,  $7.00. 

''The  work,  as  a  whole,  supplies  an  actual 
want  to  the  profession  of  this  country.  The 
subjects  treated  of  arc  destined  to  take  a  more 
and  more  prominent  place  in  the  estimation 


lessly  the  most  complete  and  comprehensive 
work  of  its  kind  in  any  language.  The  micro- 
scopic illustrations  are  unsurpassed  in  perfec- 
tion. In  mechanical  execution  the  book  is  a 
of  the  coming  doctor.  The  bookie  a  credit  beautiful  specimen  of  art.  We  seldom  see  a 
to  the  publisher  in  its  typography  and  bind-  book  of  any  kind  with  so  excellent  and  gab- 
ing." — Toledo  Medical  and  Surgical  Journal.      stantial  a  binding." — Pacific  Medical  andSur- 

••  Thi-  monnmenl  of  the  learning  and  labori-   goal  Journal. 
oub  industry  of  German  physicists,  is  doubt- j 

Belfield,  W.  T.,  M.D., 

County  Hospital;   Surgeon  to  the  Gcnito-TXrinary  Department,  Central  Dispen- 
lan  to  the  Oakwood  Betreat,  Geneva,  \Vi<. 

DISEASES  OF  Till;  I'kl.WKY  AM)  MALE  SEXUAL  ORGAXS.     Sold  by  sub- 
scription only.     See  page  52. 

Milton,  J.  L.,  M.D.,  M.R.C.S. 

THE  PATHOLOGY  AXD  TBEATMENT   OF  GONORRHOEA.      One  volume, 
318  pages,  illustrated,  muslin.     Sold  by  subscription  only.     See  page  52. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


39 


Diseases  of  the  Kidneys  and  Urinary  Organs. 


Gouley,  John  W.  S.  M.D., 


Late  Professor  of  Clinical  Surgery  and  G-enito-Urinary  Diseases  in  the  Medical  Department  of  the  Uni- 
versity of  the  City  of  New  York:  Surgeon  to  Bellevue  Hospital :  Fellow  of  the  Sew  York  Academy 
of  Medicine :  Member  of  the  New  York  Pathological  Society,  of  the  Medical  Society  of  the  County 
of  New  York,  etc. 

DISEASES  OF  THE  URINARY  ORGANS  ;  INCLUDING  STRICTURE  OF  THE 
URETHRA,  AFFECTIONS  OF  THE  PROSTATE,  AND  STONE  FN  THE 
BLADDER.  With.  103  wood-engravings.  One  volume,  8vo,  368  pages,  muslin. 
Price,  $3.75. 


"We  are  glad  to  ■welcome  this  able  con- 
tribution to  American  surgical  literature.  It 
is  not  so  exhaustive  as  the  treatises  of  Sir 
Henry  Thompson  on  Stricture  and  on  Lithot- 
omy,  nor  does  it  pretend  to  be,  but  it  is  a  very 
clearly-written  and  practical  guide,  and  -will 
be  found  useful  to  c  large  class  of  readers. 
Its  mechanical  execution  is  very  creditable, 
and  it  contains  remarkably  few  typographical 
errors." — Philadelphia  Medical  Times. 

'"  Having  on  different  occasions  during  the 
last  six  years  enjoyed  the  privilege  of  wit- 
nessing the  performance  by  Professor  Gouley 
of  some  of  the  most  difficult  and  important 


operations  on  the  genito-urinary  organs,  and 
having  been  profoundly  impressed  with  his 
consummate  skill  and  ability  as  a  practical 
surgeon,  we  hailed  with  eagerness  the  promise 
of  a  monograph  from  his  pen  on  a  class  of  dis- 
eases tc  which  he  had  given  special  attention. 
.  .  .  No  practitioner  who  undertakes  the 
treatment  of  the  urinary  organs  can  afford  to 
be  without  it.  It  will,  we  are  confident,  give 
him  a  high  position  among  the  recognized  au- 
thorities in  the  specialty  with  which  his  name 
has  been  for  some  years  honorably  associated" 
— Chicago  Medical  Xews. 


Fowler,  E.  P.,  M.D. 


SUPPRESSION  OF  URINE.       Clinical   Descriptions    and   Analysis    of   Symptoms. 
One  volume,  86  pages,  illustrated,  muslin.     Price,  $1.50. 


Millard,  H.  B.,  A.M.,  M.D. 


A  TREATISE  ON  BRIGHT'S  DISEASE  OF  THE  KIDNEYS ;  Its  Pathology.  Di- 
agnosis, and  Treatment,  with  Chapters  on  the  Anatomy  of  the  Kidney,  Albu- 
minuria, and  the  Urinary  Secretion.  One  volume,  8vo,  246  pages.  Illustrated 
with  numerous  original  illustrations.     Muslin.     Price,  §2.50. 


"It  is  rare  that  we  find  a  book  so  evidently 
the  result  of  careful,  original  study,  so  fresh 
from  the  bedside,  we  may  say,  as  the  one  be- 
fore us.  Retaining,  for  reasons  which  he 
states,  and  which  are  sound,  the  general  term 
'  Bright's  Disease,'  the  author  includes  in  his 
study  the  various  forms  of  nephritis,  which 
since  the  days  of  Dr.  Bright  have  been  recog- 
nized as  simple,  acute  and  chronic,  interstitial, 
croupous,  and  suppurative." —  The  Medical 
and  Surgical  Reporter,  Philadelphia,  Pa. 

"  This  valuable  work  contains  nearly  all 
that  is  known  in  relation  to  this  most  fatal 
disease.  This  work  is  fully  illustrated  by 
wood-cuts,  which  are  almost  entirely  original 
with  the  author  and  are  very  accurate.  They, 
alone,  give  the  reader  a  very  fair  idea  of  this 
disease." — Buffalo  Physicians'  and  Surgeons' 
Invi  stigator. 

"The  perusal  of  this  book  will  make  the 
young  physician  familiar  with  the  literature 
and  therapeutics  of  the  disease  of  which  it 
treats  without  necessitating  a  laborious  re-  • 
search  through  the  numerous  volumes  that 
have  been  written  on  the  subject." — Mirror. 

"The  only  merit  the  author  claims  for  this 
work  is  that  it  gives  the  result  of  nearly 
twenty-six  years  of  hospital  and  private  prac- 
tice, and  of  several  years'  study  in  the  labora- 
tory.    He  is  entitled  to  claim  much  more.     It ' 


is  decidedly  one  of  the  best  books  upon  the 
subject  ever  published,  and  no  one  can  read  it 
without  advantage." — The  Medical  Herald. 

"  We  have  derived  great  pleasure  from  the 
perusal  of  this  work,  a  pleasure  enhanced  by 
the  readable  type  and  excellent  quality  of  the 
paper  upon  which  it  is  printed.  We  heartily 
recommend  it  to  the  public. " — Canada  Prac- 
titioner. 

"From  stem  to  stern  the  book  presents  a 
practical  and  an  original  character  that  is 
truly  refreshing  to  the  practitioner." — Missis- 
sippi  Valley  Medical  Monthly. 

' '  Throughout  the  book  he  displays  a  remark- 
able lucidity  which  adds  greatly  to  the  pleas- 
ure and  profit  derived  from  a  perusal  of  it." — 
Canada,  Practitioru  r. 

"  Dr.  Millard  has  gone  into  the  considera- 
tion of  this  disease  in  a  very  thorough,  practi- 
cal manner.  It  is  a  work  which  will  amply 
repay  perusal  by  any  thoughtful  student." — 
Canada  Medical  Record. 

"The  author  has  written  as  one  who  not 
only  '  has  the  courage  of  his  opinions,'  but 
also  as  one  who  possesses  the  faculty  of  ex- 
pressing them  in  clear  language,  and  in  a  style 
well  deserving  of  imitation  by  not  a  few  of  the 
fast  book-makers  of  this  continent." — Canada 
Lancet. 


40        PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Diseases  of  the  Kidneys,  etc. 
Dickinson,  "W.  Howship,  M.D.,  Cantab., 

Fellow  of  the  Royal  College  of  Physicians ;  Physician  to  St.  George's  Hospital ;  Senior  Physician  to  the 
Hospital  for  Sick  Children  ;  Corresponding  Member  of  the  Academy  of  Medicine  of  New  York. 

ON  RENAL  AND  URINARY  AFFECTIONS.  This  volume  has  just  been  com- 
pleted, and  concludes  the  work  of  which  the  volume  on  Albuminuria,  published 
in  Wood's  Library  for  1881,  is  the  first  part.  Sold  by  subscription  only.  See 
page  51. 

Charcot,  J.  M.,  M.D., 

Professor  in  the  Faculty  of  Medicine  of  Paris;  Physician  to  the  Salpetriere :  Member  of  the  Academy 
of  Medicine,  of  the  Clinical  Society  of  London,  of  the  Clinical  Society  of  Buda-Pesth,  of  the  Society 
of  Natural  Sciences,  Brussels;  President  of  the  Anatomical  Society  ;  former  President  of  the  Soci- 
ety of  Biology,  etc.,  etc. 

LECTURES  ON  BRIGHT'S  DISEASE  OF  THE  KIDNEYS,  DELIVERED  AT  THE 
SCHOOL  OF  MEDICINE  OF  PARIS.  Collected  and  published  by  Drs. 
Bourneville  and  Sevestre,  editors  of  the  Progres  Medical,  and  translated, 
with  the  permission  of  the  author,  by  Henry  B.  Millard,  M.D.,  A.M.  Illus- 
trated with  two  colored  plates  and  with  wood-engravings.  One  volume,  8vo, 
100  pages,  muslin.     Price,  $1.50. 

"The  thanks  of  the  profession  are  due  to  [  "Whatever  may  be  thought  of  Professor 
the  translator,  Dr.  Millard,  for  the  way  in  \  Charcot's  views  of  the  various  forms  of  renal 
which  he  has  performed  his  portion  of  the  i  alteration,  none  can  refuse  to  him  the  merit 
work,  and  to  the  publishers  for  the  clear  type  i  of  a  profound  thinker  and  a  most  sagacious 
and  elegant  appearance  of  the  book.     It  should    observer,    the   philosophic    character    of    his 


be  read  by  every  one  who  desires  to  be  informed 
of  the  pathology  of  Bright' s  disease." — Medical 
Hi  cord. 

'  It  presents  as  clear  a  view  of  ihe  patholo- 


views  being  at  once  a  record  of  the  knowledge 
of  the  day  and  of  the  genius  of  their  author." 
—  Canada  Lancet. 

The  brochure  is  valuable  enough  to  be  well 


gy  and  histology  of  Bright's  disease  as  can  bo  '■  worth  the  study  of  every  busy  practitioner  who 
found,  and  clears  away  some  of  the  obscuri-  j  has  a  new  case  of  albuminuria  to  manage,  and 
ties  which  have  hitherto  clouded  the  study  of  '  it  will,  of  course,  find  a  place  upon  the  library 
the  important  subject." — Pacific  Medical  and  j  .-helves  of  every  one." — American  Journal  of 
Sn rgical  Journal.  I  the  Medical  Sciences. 

Stewart,  L.  Grainger,  M.D.,  F.R.S.E., 

Fellow  of  the  Royal  College  of  Physicians  ;  Physician  to  the  Royal  Infirmary  ;  Lecturer  on  Clinical  Med- 
I  Lne;  formerly  Pathologist  to  the  Royal  Infirmary ;  Lecturer  in  General  Pathology  at  Surgeons' 
i  [all,  and  Physician  to  the  Royal  Hospital  for  Sick  Children  ;  Extraordinary  Member  and  formerly 
President  of  the  Royal  .Medical  Society  of  Edinburgh. 

A  PRACTICAL  TREATISE  ON  BRIGHT'S  DISEASE  OF  THE  KIDNEYS.      One 

volume,  8vo.  334  pages,  illustrated  with  seven  lithographic  plates,  cloth.   Price, 
|4.50. 

''  Tli is  is  a  valuable  contribution  to  the  I  distinct  forms  with  which  the  name  of  Bright 
study  of  a  lass  of  diseases  which  has  enlisted  is  inseparably  and  honorably  associated.  .  .  . 
a  great  amount  of  laborious  investigation  dur-  "The  subject  throughout  is  handled  by  a 
Lng  the  last  twenty  or  thirty  years.  It  is  an  master  mind.  To  the  general  practitioner, 
original  work,  illustrated  with  plates,  exhibit-  I  and  especially  to  those  interested  in  diseases 
.  impressively  the  morbid  ohanges  of  the  kidneys,  the  work  is  invaluable."— 
which  the  kidneys  undergo  in  the  various  and  I  Pacific  Medical  and  Surgical  Journal. 

Piffard,  Henry  G.,  A.M.,  M.D., 

Profei  or  of  I  lermatology,  University  of  the  City  of  New  York  ;  Surgeon  to  the  Charity  Hospital,  etc. 

a  <;iim;  to  URINARY  analysis  for  the  use  of  physicians  and 

STUDENTS.     On.-  volume,  8vo,  89  pages,  illustrated.     Price,  $1.25. 

M  \n;i:i  \   MEDICA   AND  THERAPEUTICS  OF  THE  SKIN.      Sold  only  by  sub- 
Bcription.     Sec  page  55. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY.         41 
Syphilis,  Shin  Diseases. 
Vidal,  A.  (De  Cassis), 

Surgeon  of  the  Venereal  Hospital  of  Paris. 
A  TKEATISE  ON  VENEREAL  DISEASES.  With  colored  plates.  Translated, 
with  annotations,  hy  George  C.  Blackman,  M.D.,  Professor  of  Surgery  in  the 
Medical  College  of  Ohio  ;  Surgeon  to  the  Commercial  Hospital ;  Fellow  of  the 
Royal  Medical  and  Chirurgical  Society  of  London.  One  volume,  8vo,  499  pages, 
muslin.     Price,  $4.50. 

Taylor,  R.  W„  M.D., 

Surgeon  to  the  New  York  Dispensary,  Department  of  Venereal  and  Skin  Diseases,  Physician  to  Charity 
Hospital,  New  York. 

SYPHILITIC  LESIONS  OF  THE  OSSEOUS  SYSTEM  IN  INFANTS  AND  YOUNG 
CHILDREN.     One  volume,  8vo,  179  pages,  muslin.     Price,  $2.50. 

Keyes,  E.  L.,  A.M.,  M.D., 

Adjunct  Professor  of  Surgery,  and  Professor  of  Dermatology  in  Bellevue  Hospital  Medical  College  ; 
Consulting  Surgeon  to  the  Charity  Hospital  ;  Surgeon  to  Bellevue  Hospital,  etc. 

VENEREAL  DISEASES.     Sold  only  by  subscription.     See  page  56. 

Diday,  Paul. 

ON  SYPHILIS  IN  INFANTS.  Translated  by  Dr.  G.  Whitley.  With  Notes  and 
Additions  by  F.  R.  Sturgis,  M.D.  With  a  colored  plate.  Sold  only  by  sub- 
scription.    See  page  53. 

5£^"  In  bringing  out  an  American  edition  of  Diday's  exceptional  work,  Dr.  Sturgis,  in  his 
preface,  says  :  'l  He  believes  that  this  method  of  annotation  will  serve  to  bring  out  many 
points  in  the  pathology  and  treatment  of  Infantile  Syphilis  better  than  it  could  have  done  in 
an  independent  work." 

Busey,  Samuel  C,  M.D., 

Professor  of  the  Theory  and  Practice  of  Medicine,  Medical  Department  of  the  University  of  Georee- 
town  ;  Consulting  Physician  to  St.  Ann's  Infant  Asylum;  Attending  Physician  to  the  Children's 
Hospital :  Physician  to  the  Louise  Home ;  Ex-President  of  the  Medical  Association,  and  of  the 
Medical  Society  of  the  District  of  Columbia;  Fellow  of  the  American  Gynecological  Society  ;  Hon- 
orary Member  of  the  Medical  Society  of  the  State  of  New  York  ;  Member  of  the  Philosophical  Soci- 
ety of  Washington,  D.  C  ,  etc.,  etc. 

CONGENITAL  OCCLUSION  AND  DILATATION  OF  LYMPH  CHANNELS.  Illus- 
trated with  fiftv-six  engravings.  One  volume,  8vo,  187  pages,  muslin.  Price, 
$2.00. 

Cazenave  and  Schedel. 

MANUAL  OF  DISEASES  OF  THE  SKIN  ;  from  the  French  of  MM.  Cazenave 
and  Schedel,  with  notes  and  additions,  translated  by  T.  H.  Burgess,  M.D.  Sec- 
ond American  Edition,  enlarged  and  corrected  from  the  last  French  edition,  with 
additional  notes  by  H.  D.  Bllkley,  M.D.,  Physician  of  the  New  York  Hospital  ; 
Fellow  of  the  College  of  Physicians  and  Surgeons,  New  York  ;  Lecturer  on  Dis- 
eases of  the  Skin,  etc.,  etc.    One  volume,  8vo,  348  pages,  muslin.    Price,  $2.00. 

Liveing,  Robert,  A.M.,  and  M.D.,  Cantab.,  F.R.C.P.,  Lond., 

Lecturer  on  Dermatology  to  the  Middlesex  Hospital  Medical  School ;  Lately  Physician  to  the  Middlesex 
Hospital ;  Author  of  "Notes  on  the  Treatment  of  Skin  Diseases,"  "  Elephantiasi-  Grascorum,"  etc. 

A  HANDBOOK  ON  THE  DIAGNOSIS  OF  SKIN  DISEASES.  One  volume,  8vo, 
260  pages,  muslin.     Price,  $1.50. 

"  The  work  is  one  which  a  careful  perusal  I  in  the  field,  we  bespeak  for  it  general  favor 
would  enable  us  to  commend  even  though  its  with  the  profession.  "  — -  Michigan  Medical 
field  was  occupied  by  others,  and  as  it  is  alone  '  News. 

NOTES  ON  THE  TREATMENT  OF  SKIN  DISEASES.  One  volume,  16mo,  127 
pages,  muslin.     Price,  $1.00. 

Wilson,  Erasmus,  F.R.S. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  AND  DISEASES  OF 
THE  SKIN.     One  volume,  8vo,  445  pages,  muslin.     Price,  $3.50. 


42         PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


Shin  Diseases,  U.  S.  Pharmacopoeia. 
Fox,  Tilbury,  M.D.,  London, 

Fellow  of  the  Royal  College  of  Physicians  of  London  :  Physician  to  the  Department  for  Skin  Diseases  in 
University  College  Hospital :  Fellow  of  the  University  College. 

SKIN  DISEASES ;  their  Description,  Pathology,  Diagnosis,  and  Treatment.  Sec- 
ond American  from  Third  London  Edition,  re-written  and  enlarged.  With  a 
Cutaneous  Pharmacopoeia,  a  Glossarial  Index,  and  sixty-seven  additional  illus- 
trations.    One  volume,  8vo,  532  pages,  muslin.     Price,  $5.00. 

"The  spirit  of  industrious  and  accurate  ob-  ISmos — Am.  Pub.),  will  now  find  its  succes- 
servation  which  marks  his  writings,  and,  sor  launched  forth  as  an  imposing  octavo,  lux- 
moreover,  the  excellence  of  his  method,  com-  urious  both  as  to  paper  and  tj'pe.  This  is,  in 
mand  our  hearty  approval."  —  British  and  our  opinion,  a  great  improvement.  We  must 
"Fori  ign  Mt  dico-Chirurgical  Rt  riew.  confess  to  a  virtuous  horror  of  pocket  manuals 

A  safe  guide  to  all  who  are  engaged  in  the  as  recalling  days  when  medical  students  were 
investigation  of  skin  diseases." — The  Dublin  less  sensible  and  industrious  than,  happily, 
Quarterly  Journal  of  Medical  Science.  they  now  are.     Not  only  is  this  volume  much 

'•  We  can  heartily  recommend  it  to  the  stu-  enlarged,  but  is  also  recast  in  parts  and  re- 
dent  as  a  thoroughly  sound  and  practical  guide  written.  One  of  the  most  important  new  feat- 
to  the  study  of  diseases  of  the  skin,  in  which  ures  is  the  addition  of  many  new  illustrations, 
he  will  find  all  the  most  recent  investigations  of  which  there  are  now  nearly  one  hundred  in 
into  the  etiology  and  pathology  of  these  affec-  the  volume.  The  author  has  taken  great  pains 
tions  ;  while  to  the  practitioner  it  will  prove  to  include  the  latest  researches  in  dermatology 
an  eminently  useful  handy-book  of  reference."  in  this  edition  ;  ahd  we  can,  therefore,  unhesi- 
— Edinburgh  Medical  Journal.  tatingly  recommend  the  book  to  our  readers. 

"It  is  clear,  concise,  and  practical.  The  Without  question,  it  is  now  the  most  complete 
book  is  practical  and  richer  in  valuable  con-  and  practical  work  on  cutaneous  medicine  in 
tents  than  any  other  book  on  the  subject  of  the  English  language.  The  ordinary  student 
such  small  bulk" — Richmond  and  Louisville  ,  will  find  in  it  all  that  he  can  desire,  and  will 
Medical  Journal.  only  be  led  by  its  tone  to  wholesome  methods 

''  We  would  advise  all  practitioners  of  med-  and  higher  flights  of  research  ;  while  the  prae- 
icine  to  get  this  practical  work  and  study  it."  titioner  will  fall  back  upon  its  resources  with 
— Leav*  nworth  Medical  Herald.  satisfaction  and  with  fresh  resolves." — Notice 

'■Those  who  are  familiar  with  the  volume    of  the  new  edition  in  the  London  Lancet,  Feb- 
as  last  issued,  in  the  form  of  a  pocket  manual    ruary  8,  1873. 
(the  former  English  editions  were  small,  thick 

The  Pharmacopoeia  of  the  United  States. 

Sixth  Decennial  Revision.     By  authority  of  the  National  Convention  for  Revising 

the  Pharmacopceia  held   at  Washington.    A.D.  1880.     One  volume,  8vo,  about 

•inn   pa_res,  strongly  bound  in  muslin.     Price,    $4.00;    leather,    $5.00;    leather 

interleaved,    $6.66.     Unbound,  printed  on  one  side,  $5.00. 

"  Chief  among  the  improvements  which  ap-  adulterants."  —  Medical      Counselor,     Grand 

pear  in  the  new  Pharmacopceia  is  the  substi-  Rapids. 

tntion  of  parts  for  the  old  measurements  of  "  The  National  Pharmacopceia  is  the  stand- 

weighte." — American  Pharmacist,  New  York  arcl  authority  as  to  medical  preparations.   The 

City.  present  revised  edition  represents  the  best  c-f- 

"  The  last    edition   of    the  Pharmacopceia  forts  of  the  best  representative  men  in   the 

shows  abundant  evidence  that  the  Committee  pharmaceutical  profession  of  our  country." — 

of   Revision  have  performed  their  task  in  no  Louisville  Medical  News. 

perfunctory  manner,  but  with  an  industrious  "The  committee  certainly  have  lived  up  to 

and  conscientious  devotion  to  the  end  in  view  their  privileges.     They  have  revised  it.    Com- 

— to  make  the  book  a  closer  approach  to  per-  pared  with  1870,  it  is  almost  a  revolution,  not 

Section   than  any  of   its   predecessors." — New  a   simple   revision." — T?U    Medical   Advance, 

York  .\fiil,,;, I  Journal.  Ann  Arbor. 

■  In  addition  to  the  Pharmacopoeia  proper,  "  The  committee  devoted  a  little  more  than 
it  contain)i  an  historical  introduction,  notices  two  years  to  the  work  of  revision,  and  the  re- 
on  percolation,  temperature,  weights  and  meas-  suit  of  their  labor  is  now  before  us.  On  ex- 
list  of  reagents,  tables  of  elementary  amining  the  work  we  are  at  once  struck  with 
substances,  thermometric  equivalents,  specific  the  important  differences  that  exist  between 
gravity,  solnbihty,  saturation,  etc.,  and  sepa-  it  and  its  predecessors." — Medical  Record, 
rate  lists  of  articles  added  and  dismissed  from  January  20,  L8£ 

the  Pharmacopoeia."— J/e<3ieaZ  """'   Surgical  '•  If  once  on  the  physician's  table,  this  work 

Reportt  r.  will  probably  be  more  frequently  consulted  as 

"  The  '  get  up*  of  the  book  is  unexceptional  an  aid  to  prescribing  than  any  other  book  in 

paper   upon  which  it   is  printed  is  the  his  library,  for  it  represents  the  results  of  the 

•    printing  clear  and  distinct,  and  the  latest   scientific   researches.      The  committee 

choice   of   differenl    types    for   expressing  the  who  had  this  work  in  hand  deserve  great  credit 

names  of  drugs,  formula-,  etc.,  very  judicious."  for  bringing  the  work  up  to  the  present  needs 

— New  Remi  of  the  profession." — Med.  Rec,  Jan.  20,  1883. 

"  A  valuable  feature  of  the  new  edition  con-  "Every  medical  library  should   contain  a 

suits  of  the  various   tests  given  to  determine  copy;  also  every  pharmacist  should  own  one." 

the  purity  of   chemicals  and  the  absence  of  — The  Therapeutic  Gazette. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY.         43 
Pharmacopoeia,  etc. 
Edes,  Robert  T.,  A.B.,  M.D.   (Harvard), 

Fellow  of  the  Massachusetts  Medical  Society  ;  Fellow  of  the  American  Academy  o£  Arts  and  Sciences; 
Late  Passed  Assistant  Surgeon,  U.  S.  Navy  ;.  Professor  of  Materia  Medica  in  Harvard  University  ; 
President  of  the  American  Neurological  Association  ;  Corresponding  Member  of  the  New  York 
Therapeutical  Society ;  One  of  the  Visiting  Physicians  at  the  Boston  City  Hospital. 

THERAPEUTIC  HANDBOOK  OF  THE    UNITED    STATES   PHARMACOPOEIA. 

Being  a  condensed  statement  of  the  Physiological  and  Toxic  Action,  Medicinal 
Value,  Methods  of  Administration,  and  Doses  of  the  Drugs  and  Preparations  in 
the  Latest  Edition  of  the  United  States  Pharmacopoeia  (Apothecaries'  and  Metric 
System),  with  some  remarks  on  Unofficinal  Preparations.  One  volume,  8vo, 
300  pages,  muslin.     Price,  $3.50. 

^y  The  "  Handbook  of  the  United  States  Pharmacopoeia  "  is  intended  to  be  a  com- 
mentary, from  a  medical  rather  than  from  a  pharmaceutic  point  of  view,  upon  the  latest  edi- 
tion of  that  work,  which  is  just  completed,  and  which  contains  many  more  changes  than  have 
been  made  in  any  of  the  previous  revisions. 

As  the  Pharmacopoeia  now  stands,  it  represents  a  very  extensive  pharmaceutic  armamen- 
tarium, embracing  all  the  important  introductions  to  therapeutics  of  the  last  ten  or  perhaps 
twenty  years. 

It  is  evident  that  a  complete  treatise  on  therapeutics  is  not  to  be  looked  for  in  a  work  of 
this  size,  even  if  the  author  felt  himself  confident  to  write  one,  but  it  has  been  his  aim  to  show, 
as  succinctly  as  is  consistent  with  clearness,  what  each  drug  can  do  in  the  treatment  of  dis- 
ease, what  it  may  do  if  not  carefully  used,  and  how  far  the  various  preparations  are  fitted  to 
display  its  remedial  powers.  While  theories  erected  upon  slender  foundations  have  been  gen- 
erally neglected,  the  physiological  action  of  drugs  has  been  stated,  in  accordance  with  recent 
investigations,  so  far  as  it  bears  upon  their  practical  uses  and  upon  the  symptoms  and  treat- 
ment of  poisoning  which  may  be  occasioned  by  them.  This  knowledge,  so  far  as  obtainable, 
while  it  can  never  supplant  the  final  test  of  careful  and  unprejudiced  clinical  observation,  is 
of  the  utmost  importance  as  a  basis  for  the  rational  use  of  drugs,  and,  especially  so,  as  a  step- 
ping-stone for  the  advance  of  therapeutic  science. 

Much  attention  has  been  paid  to  the  very  important  subject  of  dosage,  and  while  the 
endeavor  has  been  to  err,  if  at  all,  on  the  side  of  safety,  the  necessity  of  producing  in  some 
cases  obvious  effects,  if  it  is  desired  to  get  therapeutic  results,  has  not  been  overlooked. 

It  is  hoped  that  this  book  will  be  found  by  the  physician  a  trustworthy  guide  in  utilizing 
the  agencies  which  the  Pharmacopoeia  places  in  his  hands,  and  by  the  pharmacist  a  brief  and 
intelligible  statement  of  what  may  be  expected  from  the  substance  he  dispenses. 


Thomson,   Anthony  Todd,  M.D.,   F.L.S., 

Fellow  of  the  Royal  College  of  Physicians  ;  Professor  of  Materia  Medica  and  Therapeutics  in  University 
College,  London,  etc. 

A  CONSPECTUS  OF  THE  PHARMACOPOEIAS  OF  THE  LONDON,  EDINBURGH, 
AND  DUBLIN  COLLEGES  OF  PHYSICIANS  AND  SURGEONS,  AND  OF 
THE  UNITED  STATES  PHARMACOPOEIA :  BEING  A  PRACTICAL  COM- 
PENDIUM OF  MATERIA  MEDICA  AND  PHARMACY.  Edited  by  Charles 
A.  Lee,  M.D.,  Professor  of  General  Pathology  and  Materia  Medica  in  General 
Medical  College.     One  volume,  18mo,  322  pages,  muslin.     Price,  §1.00. 


Foote,  John,  F.R.C.S.  (London). 

THE  PRACTITIONER'S  PHARMACOPOEIA,  AND  UNIVERSAL  FORMULARY. 

Containing  two  thousand  classified  Prescriptions,  selected  from  the  practice  of 
the  most  eminent  British  and  Foreign  medical  authorities,  etc.,  etc.  With  addi- 
tions by  Benjamin  W.  McCready,  M.  D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  College  of  Pharmacy,  New  York,  etc.  In  one  12mo  volume, 
390  pages,  muslin.     Price,  $2.00. 


Johnson,  Laurence,  A.M.,  M.D., 

Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
A  MEDICAL  FORMULARY.     Sold  only  by  subscription.     See  page  55. 


44        PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Nharmacopceia,  Nosological  Table. 
Oldberg,  Oscar,  Ph.D., 

Member  of  the  Committee  of  Revision  of  the  Pharmacopoeia  of  the  United  States  ;  Author  of  the  "  Un- 
official Pharmacopoeia,"  "  The  Metric  System  in  Medicine,"  etc.  ;  formerly  Medical  Purveyor  of  the 
United  Stiitea  Marine  Hospital  Service  ;  and  Professor  of  Materia  Medica  in  the  National  College 
of  Pharmacy,  Washington,  D.  C,  etc.  ;  and 

Wall,  Otto  A.,  M.D.,  Ph.G., 

Professor  of  Materia  Medica,  The:  apeutics,  and  Pharmacy  in  the  Missouri  Medical  College,  and  of 
Materia  Medica  and  Botany  in  the  St.  Louis  College  Pharmacy  ;  Member  of  the  Committee  cf 
Revision  of  the  Pharmacopoeia  of  the  United  States,  etc. 

A  COMPANION  TO  THE  UNITED  STATES  PHARMACOPOEIA.  Peing  a  com- 
mentary on  the  Latest  Edition  of  the  Pharmacopoeia,  and  containing  the  Descrip- 
tions, Properties,  Uses,  and  Doses  of  all  Official  and  numerous  Unofficial  Drugs 
and  Preparations  in  current  use  in  the  United  States,  together  with  Practical 
Hints,  Working  Formulas,  etc.,  designed  as  a  ready  reference  book  for  Pharma- 
cists, Physicians,  and  Students,  with  over  300  original  Illustrations.  Price,  in 
cloth,  $5.00;  in  leather,  $6.00;  in  half  morocco,  $6.50. 

jgp  The  "Companion  to  the  United  States  Pharmacopoeia "  gives  succinctly  the 
name,  synonyms  (including  all  common  or  local  English,  together  with  the  German,  French, 
Spanish,  and  Swedish  names),  origin,  habitat,  description,  varieties,  substitutions,  adultera- 
tions, common  defects,  marks  of  quality,  properties,  uses  and  doses  of  all  the  drugs  and  chem- 
icals of  which  it  treats,  and  under  each  drug  or  chemical  will  be  described  its  several  prepara- 
tions, with  formulas  for  making  these. 

All  formulas  given  are  in  definite  quantities,  solids  by  weight,  and  liquids  generally  by 
measure,  the  official  formulas  (in  parts  by  weight)  having  been  translated  accurately  according 
to  the  same  plan. 

The  book  thus  serves  as  a  key  and  companion  to  the  Pharmacopoeia.  It  gives  only  such 
information  as  pharmacists  and  physicians  most  frequently  have  occasion  to  put  to  practical 
use  in  their  daily  vocations,  and  hence  botanical  descriptions  of  plants,  except  of  the  parts 
seen  in  drugs,  chemical  processes,  accounts  of  the  physiological  actions  of  medicines,  etc.,  are 
omitted,  and  the  articles  treated  of  have  been  considered  rather  with  reference  to  actual  con- 
ditions and  requirements  of  the  trade  and  the  practice  of  the  professions  concerned  than  from 
the  standpoint  of  a  text-book. 

It  is  hoped  that  the  Companion  will  be  found  a  reliable  and  complete  pharmaceutical  and 
medical  formulary  and  dose-book,  as  well  as  a  practical  and  reliable  guide  in  the  identification 
of  crude  drugs. 

Whenever  practicable,  the  descriptions  of  drugs  are  accompanied  by  illustrations  which,  as 
a  rule,  represent  actual  specimens,  even  to  the  facsimile  reproduction  of  the  details  of  the 
venation  of  a  leaf  in  many  cases  ;  and  characters  best  shown  by  the  figures  are  not  repeated  in 
the  text,  such  as,  for  instance,  the  form  and  size  of  leaves,  etc. 

This  work  makes  a  large  octavo  volume  of  over  twelve  hundred  pages,  illustrated  by  more 
than  six  hundred  and  fifty  original  engravings  drawn  from  nature,  printed  on  fine  calendered 
paper,  and  bouud  to  match  the  Pharmacopoeia. 


Rice,  Chas.,  Ph.D., 

Chemist  to  the  Department  of  Public  Charities  and  Corrections.  New  York,  etc. 

POSOLOGICAL  TABLE,  INCLUDING  ALL  THE  OFFICINAL  AND  THE  MOST 
Ml  KOI '  KNTLY  EMPLOYED  UNOFFICINAL  PREPARATIONS.  One  volume, 
L6mo,  96  pages,  muslin.     Price,  $1.00. 

"  This  is  something  new  in  its  line.     By  a  J  and  by  certain  arbitrary  signs  which  remedies 
of  abbreviations  and  signs,  all  very  in-   are  poisonous,   which    require    caution,   and 
telligible,  the  author  bas  boiled  down  the  whole  J  some  other  points.     The   doses  are  given  in 


pliarmu<:o|Hi'ia  into  a  concentrated  extract,  fill 
j  than  100  small  pages,     A  very  conven- 
md  useful  affair." — Pacific  Medical  and 
Surgical  Journal. 

"This  table  gives  the  names  of  medicines, 
their  doses,  the  formulas  of  the  United  States 
Pharmacopoeia  and  of  other  pharmacopoeias, 


apothecaries'  weight,  and  a  table  for  convert- 
ing them  into  the  metric  system  is  appended." 
—  Medical  and  Surgical  Reporter. 

"  It  is  a  book  which  has  been  prepared  with 
much  labor  and  care,  and  is  admirably  adapted 
to  tiie  purposes  for  which  it  is  designed." — 
Maryland  Medical  Journal. 


PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 


45 


Effects  of  Drugs  ;   Chemistry,  Pictures. 


Lewin,  L.,  Dr., 

Assistant  at  the  Pharmacological  Institute  of  the  University  of  Berlin. 

THE  INCIDENTAL  EFFECTS  OF  DRUGS,  A  PHARMACOLOGICAL  AND  CLIN- 
ICAL HANDBOOK.  Translated  by  W.  T.  Alexander,  M.D.  One  volume, 
8vo,  239  pages,  muslin.     Price,  $2.00. 


"  That  individuals  vary  in  their  susceptibil- 
ity to  drugs,  and  that  idiosyncrasies  of  the 
most  unexpected  character  reveal  themselves 
in  practice,  are  observations  of  very  ancient 
date.  So  startling  are  these  accidental  effects 
that  sometimes  their  cause  is  apt  to  escape 
detection.  Variations-  in  the  phenomena  of 
disease  are  not  more  common  than  variations 
in  the  action  of  drugs,  depending  largely,  like 
the  disease  phenomena,  on  the  acquired  or  in- 
herited peculiarities   of  the   patient.      Facts  j 


belonging  to  this  category  abound  in  the  med- 
ical periodicals  and  in  the  unwritten  experi- 
ence of  doctors,  but  Dr.  Lewin  is  the  first  to 
make  a  book  by  collecting  and  classi  ying 
these  data,  and  adding  to  them  his  own  obser- 
vations sharpened  by  special  study.  He  de- 
serves credit  for  breaking  new  gi  ound  in  the 
first  place,  and  in  the  second  for  annotating, 
with  admirable  judgment,  this  somewhat  neg- 
lected branch  of  knowledge." — Louisville  Med- 
ical News. 


Witthaus,  R.  A.,  A.M.,  M.D., 

Professor  of  Medical  Chemistry  and  Toxicology  in  the  University  of  Vermont ;  Member  of  the  Chemical 
Societies  of  Paris  and  Berlin,  etc. 

A  TEXT-BOOK  OF  MEDICAL  CHEMISTRY.     Price,  muslin,  $3.50. 

"We  do  not  hesitate  to  recommend  this  "  The  author  has,  we  think,  succeeded  fairly 
work  to  the  profession  as  a  complete  text-book  in  presenting  what  every  practitioner  should 
on  the  diseases  of  which  it  treats." — Medical  ,  know  of  the  science  of  chemistry." — Philadel- 
Tribune.  \  phia  Medical  and  Surgical  Reporter. 

ESSENTIALS  OF  CHEMISTRY,  Organic  and  Inorganic  (Wood's  Pocket  Manuals) 
Price,  $1.00. 


Draper,  John  C,  M.D.,  LL.D., 


Professor  of  Chemistry  in  the  Medical  Department,  University  of  New  York,  and  of  Physiology  and 
Natural  History  in  the  College  of  the  City  of  New  York. 

A   PRACTICAL   LABORATORY    COURSE   IN    MEDICAL    CHEMISTRY.      One 

volume,  oblong  12mo,  71  pages  interleaved,  muslin.     Price,  $1.00. 

"The  book  contains,  in  a  concise  and  scien-  !  time  is  limited,  and  who  desires  practical  re- 
tific  form,  all  upon  the  above  topics  that  is  of  !  suits  with  the  least  expenditure  of  time  and 
practical  value  to  the  physician.    We  cordially    labor  and  without  the  aid  of  an  instructor." — 
recommend  it  to  physicians  and  students." —    Chicago  Medical  Times. 
Mississippi  Valley  Medical  Monthly.  "This  little  work  comprises  what  a  young 

"  In  printing  the  book  every  other  page  has  doctor  ought  to  know  about  chemistry  for  his 
been  left  blank  in  order  that  the  student  may  patients'  good." — Buffalo  Med.  and  Surg.  Jour. 
be  enabled  conveniently  to  record,  in  its  proper  i  "  It  is  bound  so  as  to  open  from  the  top,  so 
place,  the  results  of  the  experiments  he  makes,  !  as  to  easily  lie  open  on  the  table,  and,  as  it 
and  of  additional  facts  obtained  from  oral  in-    lies  open,  the  lower  page  has   been  left  blank 


struction." — Atlanta  Medical  Register. 

"  Indeed,  few  books  combine  so  much  useful 
information  in  such  a  compact,  correct,  com- 
prehensive, and  applicable  manner." — Amer- 
ican Chemical  Review. 

"  This   excellent  manual  is  one  of  the  best 


for  any  notes  and  additions  which  the  student 
desires  to  make  as  he  proceeds  with  his  work." 
—  Columbus  Medical  Journal. 

"The  student  is  indeed  to  be  congratulated 
in  being  able  to  secure  a  work  of  this  nature 
prepared  by  a  teacher  of  Dr.  Draper's  experi- 


extant  for  the   student  or  practitioner  whose  j  ence. " — The  Mediccd  Age,  Detroit. 


Pictures  for  Physicians'  Offices  and  Libraries. 

Edward  Jenner,  the    First   Inoculation  of    The  Village  Doctor. 

Vaccine,  May  14th,  1790. 
Andrew  Vesalius.  the  Anatomist. 
Spoonful  Every  Hour. 
The  Sick  Wife. 
Ambrose  Pare  Demonstrating  the  Use  of 

Ligatures. 
The  Young  Mother. 

Size  of  each,  19x24  inches.     Price,  each  $2.00 
be  sent  upon  application. 


The  Rebellious  Patient.       • 
Study  in  Anatomy. 

William  Harvey  Demonstrating  the  Circu- 
lation of  the  Blood. 
The  Anatomical  Lecture. 
The  Accident. 


Catalogues  of  these  pictures  will 


46         PUBLICATIONS  OF  WILLIAM  WOOD  &  COMPANY. 

Miscellaneous. 
Parkes,  E.,  M.D. 

A  MANUAL  OF  PRACTICAL  HYGIENE.  Edited  by  F.  S.  B.  Francois  de 
ChaumoNT,  M.D.  Sixth  edition.  With  an  Appendix.  Giving  the  American 
practice  in  matters  relating  to  hygiene.  Prepared  by  and  under  the  supervision 
of  Frederick  N.  Owen,  Civil  and  Sanitary  Engineer.  Two  volumes  in  one, 
8vo,  946  pages.  Illustrated  with  nine  full  page  plates,  and  fine  wood-engrav- 
ings, muslin  binding.     Price,  $5.00. 

Sternberg,  G.  M.,  M.D. 

BACTERIA.  By  Dr.  Antoine  Magnin,  of  Paris,  and  George  M.  Sternberg, 
M.D.,  F.R.M.S.,  Major  and  Surgeon,  U.  S.  Army.  One  volume,  8vo,  494  pages. 
Illustrated  with  twelve  full-page  plates,  including  heliotype  and  lithographic 
reproductions  of  photo-micrographs.     Muslin.     Price,  $4.00. 

Sternberg,  G.  M.,  M.D. 

MALARIA  AND  MALARIAL  DISEASES.  One  volume,  8vo,  332  pages.  Muslin 
binding.     Sold  by  subscription  only.     See  page  52. 

Sturgis,  I.  R.,  M.D. 

MEDICAL  TOPICS,  Containing  :  1.  Hints  and  Suggestions  for  Reform  in  Medical 
Education.  2.  A  Plea  for  the  State  Regulation  of  Medicine  and  Surgery.  3. 
Medical  Education  :  Its  Objects  and  Requirements.  One  volume,  8vo,  64  pages, 
paper  cover.     Price,  25  cents. 

Visiting  List  (Medical  Record),  or  Physician's  Diary. 

Containing  all  the  valuable  features  of  previous  publications  of  this  sort.  Prices : 
For  thirty  patients  a  week,  handsome  red  or  black  leather  binding,  wallet  style, 
with  or  "without  dates,  $1.25;  for  sixty  patients  a  week,  same  style,  with  or 
without  dates,  $1.50. 

Hun,  H. 

A  GUIDE  TO  AMERICAN  MEDICAL  STUDENTS  IN  EUROPE.      Price,  $1.25. 

Steel,  J.  H.,  M.D. 

OUTLINE  OF  EQUINE  ANATOMY.  A  Manual  for  the  use  of  Veterinary  Students 
in  the  Dissecting  Room.     One  volume,  12mo,  312  pages.     Muslin.     Price,  $3.00. 

Buck,  A.  H.,  M.D. 

A  TREATISE  ON  HYGIENE  AND  PUBLIC  HEALTH.  By  various  authors.  Ed- 
it. .1  by  AT.TtF.-RT  H.  Buck,  M.D.,  New  York.  In  two  volumes,  royal  8vo,  702 
and  657  pages.  Illustrated  by  numerous  wood-engravings.  (Subscription.) 
I'ricc,  per  volume,  in  muslin  binding,  $5.00  ;  in  leather,  $6.00;  and  in  nio- 
rocco,  $7.50. 

Hospital  Plans. 

FIVE  ESSAYS  Relating  to  the  Construction,  Organization,  and  Management  of  Hos- 
pitals, contributed  by  their  authors  for  the  use  of  the  Johns  Hopkins  Hospital 
oi  Baltimore,  one  volume,  8vo,  553  pages.  Illustrated  by  lithographic  plans. 
.Muslin.      Price,  $0.00. 

Johnson  and  Martin. 

tiii;  ixfli  i.xci;  of  tropical  climates  on  European  constitu- 
tions. I'.y  •!  \mes  Johnson,  M.D.,and  JAMES  Ranald  Martin,  Esq.  From 
tin-  sixth  Loudon  edition,  with  notes  by  an  American  physician.  One  volume, 
Hvo,  624  pages.      Muslin.      I 'rice,  $8.00. 

Kirby,  F.  0.,  M.D. 

A  TREAT  I SK  OX  VETERINARY  MEDICINE.  As  Applied  to  the  Diseases  and 
tnjuriei  of  the  Eorse.  Compiled  from  Standard  and  Modern  Authorities.  One 
vo'lunie.  332  pages.  Illustrated  by  four  ohromo-lithographic  plates,  containing 
numerous  figures,  and  one  hundred  and  sixty-eight  fine  wood-engravings.  Sold 
by  subscription  only.     See  page  58. 


WOOD'S  LIBEAET 


Standard  Medical  Authors. 


Iisr  announcing  the  volumes  in  this  now  celebrated  series,  it 
may  seem,  to  those  discerning  and  appreciative  gentlemen  who, 
from  the  first  have  availed  themselves  of  this  project,  unneces- 
sary to  repeat  what  we  have  said  at  different  times  in  former 
years  respecting  the  general  character  and  make-up  of  these 
books.  And  yet,  as  many  thousands  have  entered  the  profes- 
sion since  then,  we  consider  it  not  amiss  briefly  to  renew  some 
of  the  more  important  features  of  this  most  successful  scheme 
to  supply  standard  medical  literature  at  low  prices.  Until  1879 
no  attempt  had  ever  been  made  by  medical  publishers  to  pro- 
duce books  at  less  than  the  large  prices,  rendered  necessary,  in- 
deed, by  the  limited  sale  attained  by  most.  It  was  a  bold  vent- 
ure to  undertake  to  publish  twelve  volumes  in  one  year,  at  but 
one-quarter  to  one-tenth  the  prices  previously  obtained — an  un- 
dertaking which  could  only  be  successful  from  a  sale  vastly 
larger  than  before  attained. 

That  it  was  a  success,  and  a  grand  one,  is  certain  evidence 
of  the  wisdom  of  the  plan,  and  of  the  sure  support  which  the 
profession  will  always  accord  to  enterprises  conceived  and  car- 
ried out  as  this  has  been. 

In  the  seven  years  during  which  this  library  has  been  an- 
nually published, 

EIGHTY-FOUR   VOLUMES 

of  most  valuable  medical  books  have  been  issued,  at  a  cost 
to  the  regular  subscribers 

OF   ONE   HUNDRED  AND   FIVE   DOLLARS  ONLY  ; 

but  representing  books  (as  published  in  other  editions)  to  the 

VALUE   OF  NEARLY  FIVE  HUNDRED   DOLLARS. 

47 


It  would  be  impossible  for  any  publisher  to  issue  booKs 
of  the  high  character  proposed,  at  such  a  nominal  price,  un- 
less a  sale  could  be  guaranteed  for  the  series  very  much  larger 
than  is  ever  attained  by  books  as  ordinarily  published.  We 
have  contracted  with  well-known  aulhors,  eminent  in  their 
specialties,  for  new  and  original  works  upon  subjects  of  pres- 
ent interest  to  practitioners,  and  especially  conforming  to  the 
essentially  practical  character  for  which  we  desire  this  series  to 
be  known. 

If  the  expense  of  the  production  of  such  books  as  are  con- 
templated were  to  be  borne  by  the  sale  of  an  ordinary  edition, 
the  individual  cost  of  such  volumes  would  be  from  S5.00  to  87.00 
each,  and  in  several  instances  much  more.  By  combining  these 
volumes  into  sets  or  series  of  twelve  volumes  each — by  the 
closest  scrutiny  of  every  item  that  enters  into  their  cost  of 
production  and  sale — by  presenting  them  in  a  form  so  attrac- 
tive that  they  will  enlist  the  interest  of  every  lover  of  books, 
and  by  the  adoption  of  a  system  of  distribution  by  which  every 
book-buying  physician  can  have  the  opportunity  of  examina- 
tion and  purchase,  we  are  enabled  to  supply  the  series  at  the 
uniform  price  of  $18.00  each,  except  as  hereinafter  named. 

Seven  series  have  been  published,  and  we  shall  soon  enter 
upon  the  publication  of  the  eighth.  The  very  remarkable  suc- 
cess that  has  attended  this  enterprise  from  its  inception,  the 
wide-spread  support  which  it  has  continued  to  receive,  has 
served  as  a  constant  stimulant  to  further  effort  in  continuation 
of  the  libraries  upon  the  same  high  standard  of  excellence. 


PRESS   NOTICES. 

"The  publishers  are  to  be  thanked  for  their  untiring  en- 
ergy and  zeal,  in  thus  furnishing  the  profession  with  such  val- 
uable publications  at  so  low  a  price — scarcely  a  nominal  con- 
sideration." 

"  We  know  of  no  better  investment  than  a  subscription  to 
these  series." 

■■  Think  of  it !  twelve  new  books  upon  the  various  branches 
of  medicine  and  surgery,  by  the  best  writers  of  to-day,  for  only 

$18.00;" 


(From  the  original  announcement.) 

"  For  many  years  past  Messrs.  WM.  WOOD  &  CO.  have  had  under  consideration  the 
feasibility  of  producing  medical  books  by  foreign  and  American  authors,  in  good  style,, 
and  yet  at  prices  greatly  less  than  heretofore  attempted.  The  high  cost  of  labor,  and 
of  all  the  materials  used  in  the  manufacture  of  books,  has  been  an  insuperable  ob- 
stacle. Even  now  it  would  be  impossible  to  carry  out  systematically  any  such  idea  if 
the  ordinary  methods  of  trade  were  depended  upon. 

"It  is  believed  that  the  Medical  Profession  will  welcome  and  generously  sustain  any 
well-directed  effort  of  such  character,  and  consequently  the  following  scheme  has  been 
prepared  with  much  care,  and  is  respectfully  submitted  for  their  approval  and  support. 

"  The  books  selected  for  publication  in  this  series  will  be  characterized  by  the  prac- 
tical  nature  of  their  contents — so  far  as  possible — rather  than  theory.  In  general,  the 
newest  and'  most  recently  written  works  only  will  be  included  ;  occasionally  some 
standard  book,  not  readily  obtainable  or  out  of  print,  will  be  reproduced.  Reference 
to  the  titles  of  books  herein  announced  will  clearly  show  the  intent  of  the  publishers, 
and  the  wide  range  of  subjects  included. 

"In  the  niairafacture  of  these  books  there  is  nothing  omitted  essential  to  first-class 
work  ;  they  are  as  well  made  in  every  particular  as  the  high-priced  editions. 

"  A  broad-faced  Long  Primer  type  is  used,  cast  especially  for  these  volumes,  and 
with  this  type,  and  size  of  page  adopted,  these  volumes  will  contain  as  much  matter 
as  is  frequently  included  in  an  ordinary  book  of  500  to  800  pages.  The  paper  is  fine 
cream-laid,  manufactured  expressly  for  the  purpose. 

FINE    COLORED    PLATES    AND    SUPERIOR    LITHOGRAPHS 

will  be  introduced,  and  wood-engravings  will  be  freely  used  as  required.  The  covers 
are  of  the  best  hard  binders'  board,  covered  with  an  extra  quality  and  color  of  im- 
ported muslin,  and  embossed  on  the  back  and  sides  with  new  and  original  stamps.  In 
every  sense  they  will  be  honestly  made  books." 


The  above  expresses  the-purpose  of  the  publishers — as  announced  in  their  prospec- 
tus— at  the  opening  of  this  enterprise. 

(H3P  That  the  result  has  much  more  than  met  the  expectation  of  its  most  sanguine 
friends  and  supporters  is  well  knoicn  to  every  book-buying  member  of  the  profession. 

The  production  in  these  series  of  such  works  as  : 

Savage's — "  Female  I*elvic  Organs." 

Ellis  and  Ford's-"  Illustrations  of  Dissections." 

Munde's — "  CJynecoIogy." 

Hart  and  Darh©ur's — "  Diseases  of  Women." 

Carpenter's—"*  Microscope  and  its  Revelations." 

Park's — "  Hygiene,"  with  its  "  American  Appendix." 

Kirfoy's— "  Diseases  and  Injuries  of  the  Horse." 

Holden's — "  Human   Osteology." 

•Johnson's—"  Medical  Botany." 

Hfoyes' — "  Diseases  ©f  the  Eye." 

Kirhcs' — 'v  l*hysiol©gy,"  and  very  many  others. 

— with  all  their  wealth  of  illustrations  in  colored  plates  and  fine  wood-engravings — has 
been  an  ever- recurring  matter  of  gratification  to  the  subscribers,  and  an  occasion  of 
surprise  even  to  bookmakers,  at  the  facilities  and  possibilities  of  the  bookmaking  of 
to-day,  as  developed  by  the  publishers  of  these  remarkable  volumes. 

JC^3  Detailed  information  regarding  the  volumes  published  in  each  series  will  be 
found  upon  the  following  pages,  to  which  the  most  careful  attention  and  scrutiny  is 
invited  upon  the  part  of  the  careful  book-buyer. 

4:9 


Woods  Library  of  Standard  Medical  Authors. 


"  This  is  certainly  a  bold  undertaking,  and  can  only  be  successful  by  a  liberal  sup- 
port from  the  profession. " 

' '  One  of  the  reasons  why  medical  books  are  so  expensive,  as  compared  with  books 
in  general  literature,  is  their  comparatively  limited  sale. " 

"  Of  course  the  only  way  in  which  the  enterprise  can  pay  its  originators  is  in  an 
immense  subscription  list,  and  we  earnestly  ask  for  a  general  support  along  our  line." 

"  The  publishers  look  for  the  support  of  the  profession  in  this  enterprise." 

"  The  scheme  is  one  which  the  profession  should  endorse." 

"  This  will  furnish  progressive  men  with  a  rare  opportunity  to  procure  new  books  at 
exceedingly  low  figures." 

'■  Most  of  these  volumes  will  be  illustrated.  Nothing  yet  offered  will  at  all  com- 
pare with  this  proposition. " 

"  As  this  series  is  an  experiment,  we  hope  it  will  prove  sufficiently  remunerative  to 
warrant  a  continuance  during  future  years.  The  terms  are  so  reasonable  that  a  library 
of  the  best  authors  is  now  within  the  reach  of  all." 

'•  We  honestly  believe  that  every  medical  man  in  the  profession  should  enter  his 
name  us  a  subscriber." 

"  Wm.  Wood  A:  Co.  make  it  possible  for  every  practitioner,  however  poor  his  purse, 
to  furnish  his  library  with  proper  works,  and  they  should  receive  the  heartiest  support 
from  the  profession!*' 


The  above  Press  Notices  show  the  welcome  given  to  the  enterprise 

at  its  inception. 

Bow  fully  the  result  met  the  expectation  of  the  Press,  the  following  notices 
among  thousands  will  serve  to  show  : — 

"They  are  handsome,  inside  and  out; 
first  el- 


paper,  type,  presswork  and  binding  are  all 


"  In  the  mechanical  execution  of  the  books  and  the  artistic  work,  especially,  it  is 
hut  faint  praise  to  say  they  arc  far  above  the  average  of  medical  publications." 

•  The  character  of  the  works  and  the  amazing  cheapness  of  the  publication  recom- 
mend this  library  to  all  practitioners. " 

"  We  are  surprised  that  such  books  can  be  furnished  for  the  money.  The  get-up 
of  the  books  is  in  every  respect  equal  with  the  high-priced  editions  now  being  sold." 

50 


Wood's  Library  of  Standard  Medical  Authors. 

IFOIR,  1835. 
Seventh  Series.    Price,  $     .      .    Volumes  not  sold  separately. 


HUMAN  OSTEOLOGY.  Comprising  a  Description  of  the  Bones,  with  Delineations  of  the  Attachments 
of  the  Muscles,  the  General  and  Microscopic  Structure  of  Bone  and  Its  Development.  By  LUTHER 
HOLDEN,  Ex- President  and  Member  of  the  Court  of  Examiners  of  the  Royal  College  of  Surgeons  of 
England ;  Consulting  Surgeon  to  Saint  Bartholomew's  and  the  Foundling  Hospitals ;  assisted  by 
JAMES  SHUTER,  F.R.C.S.,  M.A.,  M.B.  Cantab.,  Assistant  Surgeon  to  the  Royal  Free-Hospital ;  late 
Demonstrator  of  Physiology,  and  Assistant  Demonstrator  of  Anatomy,  at  Saint  Bartholomew's  Hospi- 
tal.    Sixth  Edition.     With  66  full-page  lithographic  plates  and  89  wood-engravings. 

jpg~  This  is  another  of  these  marvels  of  bookmaking  for  which  Wood's  Library  has  become  celebrated. 

KIRKES'  HANDBOOK  OF  PHYSIOLOGY.  By  W.  MORRANT  BAKER,  F.R.C.S.,  Surgeon  to  Saint 
Bartholomew's  Hospital  and  Consulting  Surgeon  to  the  Evelina  Hospital  for  Sick  Children  ;  Lecturer 
on  Physiology  at  Saint  Bartholomew's  Hospital,  and  late  Member  of  the  Boated  of  Examiners  of  the 
Royal  College  of  Surgeons  of  England ;  and  VINCENT  DORMER  HARRIS,  M.D.  Lond.,  Demon- 
strator of  Physiology  at  Saint  Bartholomew)' s  Hospital.  Eleventh  Edition. 
Volume  I.     With  a  Colored  Plate  and  253  illustrations. 

SE3P=  Kirkes'  Physiology  has  long  enjoyed  a  high  reputation  as  one  of  the  best  and  most  practical 
works  of  its  kind,  and  in  this  r.ew  edition,  just  completed  by  Drs.  Baker  and  Harris,  is  probably  as  ac- 
ceptable a  book  on  the  subject  as  could  be  presented  to  the  practitioners  of  America. 

THE  SAME.     Volume  II.     With  nearly  250  illustrations. 

ON  THE  WASTING  DISEASES  OF  INFANTS  AND  CHILDREN.  By  EUSTACE  SMITH, 
M.D.,  Lond.,  Fellow  of  the  Royal  College  of  Physicians ;  Physician  to  his  Majesty  the  King  of  the  Bel- 
gians ;  Physician  to  the  East  London  Children's  Hospital  and  to  the  City  of  London  Hospital  for 
Diseases  of  the  Chest,  Victoria  Park.     Fourth  Edition. 

$^T~  This  work,  upon  a  phase  of  disease  seldom  treated  of  in  ordinary  medical  text-books  or  the  prac- 
tice of  Medicine,  is  by  the  accomplished  author  of  "  Disease  in  Children,"  recently  published  by  this 
house. 

A  TREATISE  ON  CHOLERA.  Edited  and  prepared  by  EDMUND  C.  WENDT,  M.D.,  Curator  of  the 
Saint  Francis  Hospital ;  Pathologist  and  Curator  of  the  New  York  Infant  Asylum,  etc.,  etc.;  in  asso- 
ciation with  JOHN  C.  PETERS,  M.D.,  New  York  ;  JOHN  B.  HAMILTON,  M.D.,  Surgeon-General  U. 
S.  Marine  Hospital  Service,  and  ELY  McCLELLAN,  M.D.,  Surgeon  U.  S.  Army.  Illustrated  with 
maps  and  engravings. 

H£ir°  Availing  themselves  of  the  history  and  experience  of  Cholera  Epidemics  to  the  present  day,  to- 
gether with  the  new  light  thrown  upon  its  mode  of  propagation,  spread,  and  treatment  the  past  year 
through  the  investigations  of  Professor  Koch  and  others — the  knowledge  concerning  preventive  meas- 
ures, quarantine,  etc.,  so  recently  acquired  in  France  and  Italy — the  learned  authors  of  this  work  aimed 
to  produce  a  book  which  may  at  least  serve  to  prepare  the  profession  of  America  successfully  to  combat 
this  dreaded  scourge,  should  it  unfortunately  gain  an  entrance  into  our  country.  Being  written  spe- 
cially for  Wood's  Library,  and  wholly  since  the  first  of  this  year,  it  is  the  only  treatise  of  any  kind  fully 
up  to  the  most  recent  discoveries. 

POISONS  :  THEIR  EFFECTS  AND  DETECTION.     A  Manual  for  the  Use  of  Analytical  Chemists 
and   Experts,  with   an    Introductory  Essay  on   the  Growth  of   Modern  Toxicology.     By  ALEXANDER 
WYNTER  BLYTH,  M.R.C.S.,  F.C.S.,  etc.,  Public  Analyst  for  the  County  of  Devon,  and  Medical  Of- 
ficer of  Health  and  Public  Analyst  for  Saint  Marylebone. 
Volume  I.     With  tables  and  illustrations. 

JU^T"  This  is  the  most  recent  treatise  upon  this  important  subject,  and  is  full  and  complete — a  perfect 
storehouse  of  valuable  information. 

THE  SAME.     Volume  II.     With  tables  and  illustrations. 

ON  RENAL  AND  URINARY  AFFECTIONS.  Miscellaneous  Affections  of  the  Kidneys  and  Urine. 
By  W.  HOWSHIP  DICKINSON,  M.D.  Cantab.,  Felloio  of  the  Royal  College  of  Physicians  ;  Phy- 
sician to  Saint  George's  Hospital ;  Senior  Physician  to  the  Hospital  for  Sick  Children ;  Correspond- 
ing Member  of  the  Academy  of  Medicine  of  New  York. 

Jt3F°  This  volume  has  just  been  completed,  and  concludes  the  work  of  which  the  volume  on  Albumi- 
nuria, published  in  this  Library  for  1881,  is  the  first  part. 

EPILEPSY  AND  OTHER  CHRONIC  CONVULSIVE  DISEASES.  Their  Causes,  Symptoms,  and 
Treatment,  By  W.  R.  GOWERS,  M.D.,  F.R.C.P.,  Assistant  Professor  of  Clinical  Medicine  in  Univer- 
sity College ;  Senior  Assistant  Physician  to  University  College  Hospital ;  Physician  to  the  National 
Hospital  for  the  Paralyzed  and  Epileptic. 

J5&™  Specially  revised  by  the  author  for  Wood's  Library. 

CLIMATOLOGY  OF  THE  UNITED  STATES,  AND  ADJACENT  COUNTRIES,  and  of  such 
Foreign  Ports  and  Places  as  have  intimate  Commercial  Relations  with  the  United  States,  with  special 
reference  to  Health  Resorts,  and  the  Protection  of  Public  Health.  By  A.  N.  BELL,  A.M.,  M.D.,  Ed- 
itor of  "  The  Sanitarian  ;  "  Member  of  American  Medical  Association,  American  Public  Health  Asso- 
ciation, Medical  Society  of  the  State  of  New  York  ;  Honorary  Member  of  Connecticut  Medical  Society ; 
Corresponding  Member  of  the  Epidemiological  Society  of  London, •  formerly  P.  A.  Surgeon  U.  S. 
Navy,  ect. 

855?"  This  work  has  been  written  specially  for  Wood's  Library,  by  one  whose  training  and  study  have 
been  for  many  years  in  this  line. 

DISEASES  OF  THE  LUNGS,  OF  A  SPECIFIC,  NON-TUBERCULOUS  NATURE.  Acute 
Bronchitis,  Infectious  Pneumonia,  Gangrene,  Syphilis,  Cancer,  and  Hydatids  of  the  Lungs.  By  PROF. 
GERMAIN  s£E,  Member  of  the  Faculty  of  Medicine  ;  Member  of  the  Academy  of  Medicine  ;  Physician 
to  the  Hotel  Dieu,  etc.,  Paris.  Translated  by  E.  P.  HURD,  M.D.,  Member  of  the  Massachusetts  Med- 
ical Society ;  Vice-  President  of  the  Essex  North  District  Medical  Society  ;  One  of  the  Physicians  of  the 
Anna  Jaques  Hospital,  Newburyport,  Mass.  With  an  Appendix  by  the  Translator  on  the  German 
Theory  of  Disease,  and  on  the  Tubercle  Bacillus. 

13^*"  One  of  the  most  valuable  works  on  the  subject  of  recent  times — fully  up  to  date. 

DIAGNOSIS  OF  THE  DISEASES  OF  THE  BRAIN  AND  SPINAL  CORD.  By  W.  R.  GOWERS, 
M.D.,  F.R.C.P.,  Assistant  Professor  of  Clinical  Medicine  in  University  College  ;  Senior  Assistant  Phy- 
sician  to  University  College  Hospital ;  Physician  to  the  National  Hospital  for  the  Parahjzed  and  Epi- 
leptic. 

51 


Catalogue  of  the  Titles  of  the  Works  published  in 

Woods  Library  of  Standard  Medical  Authors. 


1884. 


Sixtli  Scries.    Price,  $1§.00,    Volumes  not  sold  separately. 


LEGAL  MEDICINE.  By  CHARLES  MEYMOTT  TIDY,  M.D.,  F.C.S.,  Master  of  Surgery,  Professor 
of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  Medical  Qfflctr  oj 
Health  for  Islington,  Late  Diputy  Medical  Officer  of  Health  and  Public  Analyst  for  the  City  of  London, 
etc.  Volume  III.  Contents  :  Legitimacy  and  Paternity — Pregnancy,  Abortion — Rape,  Indect-nt  Ex- 
posure— Sodomy,  Bestiality — Live  Birth,  Infanticide — Asphyxia,  Drowning — Hanging,  Strangulation — 
Suffocation. 

PATHOLOGY  AND  TREATMENT  OF  GONORRHOEA.  By  J.  L.  MILTON,  M.D.,  M.R.C.S., 
Lecturer  on  Diseases  of  the  Skin,  St.  John's  Hospital  for  Skin  Diseases,  etc. 

i&~ This  work  is  fresh  from  the  author's  hands,  and  treats  in  a  very  practical  way  of  this  common 
disorder. 

DIAGNOSIS  AND  DISEASES  OF  THE  HEART.  By  Db.  CONSTANTINE  PAUL,  Professor  Agrege 
in  the  Faculty  of  Medicine  of  Paris,  etc.     Illustrated  by  numerous  fine  wood  engravings. 

A  PRACTICAL  MANUAL  OF  OBSTETRICS.  By  E.  VERRIER,  M.D.  Translated  from  the  French. 
Edited  by  E.  L.  PARTRIDGE,  M.D.     Profusely  illustrated  with  fine  wood  engravings. 

HOOPER'S  PHYSICIAN'S  VADE  MECUM  :  A  Manual  of  the  Principles  and  Practice  of  Physic  ;  with 
an  Outline  of  General  Pathology,  Therapeutics  and  Hygiene.  Tenth  Edition.  Revised  by  WILLIAM 
AUGUSTUS  GUY,  M.B.,  Cantab,  F.R.S.,  JOHN  HARLEY,  M.D.,  Lond.,  F.L.S.  Volume  I.  Illus- 
trated by  wood  engravings. 

HOOPER'S  PHYSICIAN'S  VADE  MECUM  :  A  Manual  of  the  Principles  and  Practice  of  Physic ;  with 
an  Outline  of  General  Pathology,  Therapeutics  and  Hygifne.  Tenth  Edition.  Revised  by  WILLIAM 
AUGUSTUS  GUY,  M.B.,  Cantab,  F.R.S.,  JOHN  HARLEY,  M.D.,  Lond.,  F.L.S.  Volume  II.  Illus- 
trated by  wood  engravings. 

MALARIA  AND  MALARIAL  DISEASES.  By  GEORGE  M,  STERNBERG,  M.D.,  F.R.M.S.,  Major 
and  Surgeon  United  States  Army ;  Member  of  the  Biological  Society  of  Washington  ;  Late  Member  of 
the  Havana  Yelloio  Fever  Commission  of  the  National  Board  of  Health,  etc.     Illustrated. 

DISEASES  OF  THE  OESOPHAGUS,  NOSE  AND  NASO-PHARYNX.  By  MORRELL  MACKENZIE, 
MO.,  London,  Senior  Physician  of  the  Hopital  for  the.  Diseases  of  the  Chest  and  Throat,  Lecturer 
on  Diseases  oj  the  Throat  at  Lond  m  Hospital  Medical  College,  etc.     Illustrated  by  wood  engravings. 

528'" The  companion  volume  of  this  work,  namely,  "Diseases  of  the  Pharynx,  Larynx  and  Trachea," 
was  published  in  the  Library  for  1880,  and  elicited  the  warmest  commendation  from  the  medical  press 
of  England  and  America. 

A  TEXT-BOOK  OF  GENERAL  PATHOLOGICAL  ANATOMY  AND  PATHOGENESIS.  By 
ERNST  ZIEQXjER,  Professor  of  Pathological  Anatomy  in  the  University  of  Tubingen.  Translated 
and  edited  for  English  Students  by  DONA  LD  MACALISTER,  A.M.,  M.B.,  Member  of  the  Royal  College 

if  Pin,    ■■  inn  .  ;    I', Hi, hi  iiinl    Umlinil  /.,:■/ n,->r  of  St.  ■John's  College,  Cambridge. 
Part  II — Special  Pathological  Anatomy.     Sections  I-VIII.     Profusely  illustrated. 

DISEASES  OF  THE  URINARY  AND  MALE  SEXUAL  ORGANS.     By  WM.  T.  BELFIELD,  M.D. 

BRONCHIAL  AND  PULMONARY  DISEASES.  By  PR03SER  JAMES,  M.D.,  Lecturer  on  Materia 
IfeOica  and  Therapeutics  at  the  London  Hospital;  Physician  to  the  Hospital  for  Diseases  of  the  Throat; 
Lute  Physician  to  the  North  London  Consumptive  Hospital,  etc.  Illustrated  by  numerous  wood 
engravlngf. 

MEDICAL  BOTANY  :    A  Treatise  on  Plants  used  in  Medicine.   By  LAURENCE  JOHNSON,  A.M.,  M.D., 
Itrer  on  Medical  Botany,  Medical  Department  of  the  University  of  the  City  of  New  York  ;  Fellow 
of  the  New  York  Academy  of  Medicine,  etc.     Illustrated  by  nine  beautifully  colored  plates  and  very 
DOmerona  fine  wood  engravings. 

:>-± 


Wood's  Library  of  Standard  Medical  Authors 


Fifth  Series.     Price,  wis. 00.     Volumes  not  sold  separately. 


MANUAL  OF  GYNECOLOGY.  By  D.  BENJ.  HART,  M,D.,  F.R.C.P.E.,  Lecturer  on  Midwifery 
and  Diseases  of  Women,  School  of  Medicine,  Edinburgh,  etc.,  etc.;  and  A.  H.  BARBOUR,  M.A.,  B.Sc, 
M.B.,  Assistant  to  the  Professor  of  Midwifery,  University  of  Edinburgh.  Volume  1.  Illustrated  with 
eight  plates,  two  of  which  are  in  colors,  and  192  fine  wood  engravings. 

MANUAL  OF  GYNECOLOGY.  By  D.  BENJ.  HART,  M.D.,  F.R.C.P.E.,  Lecturer  on  Midwifery 
and  Diseases  of  Women,  School  of  Medicine,  Edinburgh,  etc.,  etc.;  and  A.  H.  BARBOUR,  M.A.,  B. 
Sc,  M.B.,  Assistant  to  the  Professor  of  Midwifery,  University  of  Edinburgh.  Volume  II.  Illustrated 
with  a  lithographic  plate  and  209  fine  wood  engravings. 

THE  DISEASES  OF  WOMEN.  A  Manual  for  Physicians  and  Students.  By  HEINRICH  FRITSCH. 
M.D.,  Professor  of  Gynecology  and  Obstetrics  at  the  University  of  Halle.  Translated  by  ISIDORE 
FURST.     Illustrated  with  150  fine  wood  engravings. 

THE  MICROSCOPE  AND  ITS  REVELATIONS.  By  WM.  B.  CARPENTER,  C.B.,  M.D.,  LL.D. 
Sixth  Edition.  Volume  I.  Illustrated  by  one  colored  and  26  plain  plates,  and  502  fine  wood 
engravings. 

THE  MICROSCOPE  AND  ITS  REVELATIONS.  By  WM.  B.  CARPENTER,  C.B.,  M.D.,  LL.D. 
Sixth  Edition.    Volume  II.    Illustrated  with  26  plates  and  502  fine  wood  engravings. 

HANDBOOK  OF  ELECTRO-THERAPEUTICS.  By  DR.  WILHELM  ERB,  Professor  in  the  Univer- 
sity of  Leipzig.     Illustrated  by  39  wood  engravings. 

A  TEXT-BOOK  OF  GENERAL  PATHOLOGICAL  ANATOMY  AND  PATHOGENESIS.  By 
ERNST  ZIEGLER,  Professor  of  Pathological  Anatomy  in  the  University  of  Tubingen.  Translated 
and  edited  for  English  students  by  DONAL  McALISTER,  A.M.,  M.B.,  Member  of  the  Royal  College  of 
Physicians  ;  Fellow  and  Medical  Lecturer  of  St.  Joh?iys  College,  Cambridge. 

THE  TREATMENT  OF  WOUNDS.  Being  a  Treatise  on  the  principles  upon  which  the  Treatment  of 
Wounds  should  be  founded,  and  on  the  best  methods  of  carrying  them  into  practice,  including  a  con- 
sideration of  the  modifications  which  special  injuries  may  demand.  By  LEWIS  S.  PILCHER,  A.M., 
M.D.,  of  Brooklyn,  N.  Y.     Illustrated  by  wood  engravings. 

A  MANUAL  OF  PRACTICAL  HYGIENE.  By  EDMUND  A.  PARKES,  M.D.,  F.R.S.,  Late  Pro- 
fessor of  Military  Hygiene  in  the  Army  Medical  School ;  Member  of  the  General  Council  of  Medical 
Education  ;  Fellow  of  the  Senate  of  the  University  of  London ;  Emeritus  Professor  of  Clinical  Medi- 
cine in  University  College,  London.  Edited  by  F.  S.  FRANCOIS  DeCHAUMONT,  M.D.,  F.R.S., 
Fellow  of  the  Royal  College  of  Surgeons,  Edinburgh  ;  Fellow  and  Chairman  of  the  Sanitary  Institute 
of  Great  Britain;  Professor  of  Military  Hygiene  in  the  Army  Medical  School.  Sixth  Edition. 
Volume  I. 

A  MANUAL  OF  PRACTICAL  HYGIENE,  WITH  AN  APPENDIX.  Giving  the  American 
practice  in  matters  relating  to  Hygiene,  prepared  by  and  under  the  supervision  of  FREDERICK  N. 
OWEN,  Civil  and  Sanitary  Engineer.     Illustrated  by  chromo  lithographic  plates.    Volume  II. 

ON  SYPHILIS  IN  INFANTS.  B7  PAUL  DIDAY.  Translated  by  DR.  G.  WHITLEY.  With  Notes 
and  Additions  by  F.  R.  STURGIS,  M.D.     With  a  Colored  Plate. 

ISlf"  In  bringing  out  an  American  edition  of  Diday's  exceptional  work,  Dr.  Sturgis  in  his  preface 
says:  "He  believes  that  this  method  of  annotation  will  serve  to  bring  out  many  points  in  the  Pathology 
and  Treatment  of  Infantile  Syphilis  better  than  it  could  have  done  in  an  independent  work." 

A  TREATISE  ON  VETERINARY  MEDICINE,  as  Applied  to  the  Diseases  and  Injuries  of  the 
Horse.  Compiled  from  standard  and  modern  authorities.  By  F.  O.  KIRBY.  Illustrated  by  4  chromo- 
lithographic  plates,  containing  numerous  figures  and  about  150  fine  wood  engravings. 

53 


f jp  Library  of  Standard  Medical  Authors. 

Fourth  Series.    Price,  £1§.©0.    Volume*  not  sold  separately. 

ILLUSTRATIONS  OF  DISSECTIONS.  In  a  series  of  original  colored  plate?,  representing  the  dissoc-  •> 
tions  of  the  human  body,  with  descriptive  letter-press.  By  GKORGE  VINER  ELLIS,  Professor  of  Jjj 
Anatomy  in  University  College,  London,  and  G.  H.  FORD,  Esq.  The  drawings  are  from  nature  by  *o 
Mr.  Ford,  from  directions  by  Prof.  Ellis.  Volume  I.  Containing  29  full  page  chromo-lithographic  • 
plates.  © 

ILLUSTRATIONS  OF  DISSECTIONS.     In  a  series  of  original  colored  plates,  representing  the  dissec-      ~ 
lions  of  the  human  body,  with  descriptive  letter-press.      By  GEORGE  VINER  ELLIS,  Professor  of 
Anatomy  in  University  College,  London,  and  G.  H.  FORD,  Esq.    Volume  II.     Containing  27  full- page      &* 
chromo-lithographic  plates.  & 

|3|f"  When,  in  the  second  series,  we  succeeded  in  presenting  our  subscribers  with  "  Savage's  Female  £ 
Pelvic  Organs,''  will  its  full-page  lithographic  plates,  we  supposed  we  had  reached  the  extreme  limit  in  •J 
reproducing  expensive  books  at  so  low  a  price,  but  these  two  volumes  of  Ellis  and  Ford  far  exceed  even  - 
that.  It  is  simply  wonderful,  and  cannot  fail  to  compel  acknowledgment  of  the  value  of  this  series  of  6 
publications.  It  would  have  been  impossible  to  accomplish  such  results,  save  in  a  library  such  as  this,  * 
in  which  all  the  volumes  have  a  large  and  equal  sale. 

LECTURES  ON  DISEASES  OF  CHILDREN.     A  Hand-book  for  Physicians  and  Students.     By  Dr.      <£ 
EDWARD    HENOCH,  Director  of  the  Clinic  and  Polyclinic  for  Diseases  of  Children  in  the  Royal      2 
Ch ante  Hospital  and  Professor  in  the  Berlin  University.      Translated  from  the  German.      B3F~  A  new 
book,  just  ready,  and  of  ereat  practical  value.  g 

MATERIA   MEDICA    AND     THERAPEUTICS.      Inorganic    Substances.      Ey   CHARLES    D.   F.      <g 
PHILLIPS,  M.D..  F.R.C.S.E.,  Lecturer  on  Materia  31  edica,  Westminster  Hospital,  London.     Adapted 
to  the  United  States  Pharmacopoeia.    By  LAWRENCE  JOHNSON,  M.D.     Volume  I.  ® 

MATERIA  MEDICA  AND  THERAPEUTICS.  Inorganic  Substances.  By  CHARLES  D.  F.  Z 
PHILLIPS.  M.D.,  F.R.C.S.E.,  Lecturer  on  Materia  Medica,  Westminster  Hospital,  London.  Adapted  . 
to  the  United  States  Pharmacopoeia.     By  LAWRENCE  JOHNSON,  M.D.     Volume  II.  Z 

gag*~  Since  the  publication  of  the  learned  author's  treatise  on  the  Materia  Medica  and  Therapeutics  of  JJ 
the  vegetable  kingdom,  in  the  first  series,  there  has  been  a  continued  inquiry  for  this  promised  con-  8 
tinuation.  We  are  happy  to  be  able  now  to  present  it  fresh  from  the  hands  of  Dr.  Phillips,  and  pub-  i- 
li.-he  1  in  Wood's  Library,  bv  special  arrangement  with  him.  «■   • 

PRACTICAL  MEDICAL  ANATOMY.  A  guide  to  the  physician  in  the  Study  of  the  Relations  of  the  s^ 
Viscera  to  each  other  in  Health  and  Disease,  and  in  the  Diagnosis  of  the  Medical  and  Surgical  Conditions  •-•» 
of  the  Anatomical  Structures  of  the  Head  and  Trunk.  By  AMBROSE  L.  RANNEY,  A.M..  M.D.,  Ad-  "Op, 
junct  Professor  of  Anatomy  and  late  Lecturer  on  Genitourinary  and  Minor  Surgery  in  the  Medical  ?a, 
Department  of  the  University  of  the  City  of  New  York;  late  Surgeon  to  the  Northern  and  North-  ;S 
western  Dispensaries  ;  Resident  Fellow  of  the  New  York  Academy  of  Medicine  ;  Member  of  the  Medi-  J»  * 
cal  Society  of  the  County  of  New  York  ;  Author  of  "  Ihe  Applied  Anatomy  of  the  Nervous  System,'''1  «  e 
"A  Practical  Treatise  on  Surgical  Diagnosis,'''  "The  Essentials  of  Anatomy ',"  etc.,  etc.  Illustrated  J*1* 
by  fine  wood  engravings. 

£r??"~  This  work  occupies  a  new  field  in  Anatomv  of  an  exceedinglv  practical  character. 

MENTAL  PATHOLOGY  AND  THERAPEUTICS.  By  W.  GRIE3INGER,  M.D.,  Professor  of 
Clinical  Medicine  and  of  Medical  Science  in  the  University  of  Berlin  ;  Honorary  Member  of  the 
MediCO-Physiological  Association  ;  Membre  Associe  Etranger  de  la  Societe  Medico- Physiologique  de 
Parti,  etc.,  etc.  Translated  from  the  German  by  C.  LOCKHART  ROBERTSON,  M.D.,  Cantab,  Medical 
rintendeni  of  the  Sussex  Lunatic  Asylum,  Haywards  Heath,  and  JAMES  RUTHERFORD,  M.D., 
Edinburg. 

%&~  The  first  edition  of  this  standard  work  appeared  in  1S45.  and  coming  from  the  acknowledged 
leader  of  the  modern  German  school  of  Medical  Psychology,  it  at  once  became  the  recognized  authority 
upon  the  Subject  of  which  it  treats.  The  various  editions  and  translations  since,  have  maintained  its 
high  position  ami  enhanced  the  estimation  in  which  it  is  held  bv  all  students  of  medical  metaphysics. 

DISEASES  OF  THE  RECTUM  AND  ANUS.  By  CHARLES  D.  KELSEY,  M.D.,  Surgeon  to  St. 
Pours  Infirmary  for  Diseases  of  the  Rectum;  Consulting  Surgeon  for  Diseases  of  the  Rectum,  to 
the  Ilia  l'  in  Hospital  and  Dispensary  for  Women  and  Children,  etc.,  etc. 

ON  ASTHMA:    ITS   PATHOLOGY   AND   TREATMENT.     By  HENRY  HYDE  SALTOR.  M.D., 
F. U.S..  Fellow  of  the  Royal  College  of  Physicians;  Physician  to  Charing  Cross  Hospital,  and  Lec- 
tin-, r  mi  tin    Principles  and  Practice  of  Medicine,  at  the  Charing  Cross  Hospital  Medical  School. 
|3T"Fir-t  American  from  the  last  English  edition. 

RHEUMATISM.  GOUT,  AND  SOME  OF  THE  ALLIED  DISEASES.  By  MORRIS  LONG- 
S'!']; KTI  I.  M.l>.. 

|  •  The  \\..rk  treats  the  subject  it  relates  to,  from  an  American  stand-point,  the  works  heretofore  in 
the  market  being  of  foreign  origin.  It  will,  therefore,  be  a  very  practical  volume,  for  the  Ube  of  physi- 
i  km-  throughout  t  his  COlintry.  p, 

LEGAL  MEDICINE.  By  CHARLES  MEYMOTT  TIDY,  M.B.,  F.C.S..  Master  of  Surgery.  Professor  9 
of  Chemistry  and  of  Forensic  Medicine  ami  Public  Health  at  the  Condon  Hospital,  Medical  Officer  of  p, 
Health  for  Tsltnaton,  i.ut'-  Deputy  Medical  Officer  of  Health  and  Public  Analyst  for  the  City  of  L<>i>-     >, 

Oon,  etc.      Volume  I.      With  two  colored  plates.      Contents:    Evidence— The  Signs  of  Death— Identity—      'g 
The  Cannes  of  Death  -  The  p0st  .Mortem.  » 

LEGAL  MEDICINE.     By  CHARLES  MEYMOTT  TIDY.   M.D..  F.C.S.,  Master  of  Surgery,  Professor      *> 
of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  Medical  Officer  oj     * 
//•  .I!'),  for  Islington,  /.ai-  Deputy  tt<  ileal  Officer  of  Health  and  Public  Analyst  for  the  City  of  London,      * 
Volume   II.     Contents:  Expectation  of  Life— presumption  of  Death  and  Survivorship— Heat  and       V 
1  -Ligaturing— Explosives— Starvation— Sex— Monstrosities— Hermaphrndi.-ni.  £• 

for    a  thorough   and    exhanBfcive    treatise  upon    this    subject    from   some   recognized      S* 
authority   has  long  been  felt  in    English  speaking  countries.      But  the  labor  of  preparing  such  a  work  is      L 
Ions,  requiring  BUCh  critical   acumen  anil   familiarity  with   both  medicine  and  law,  together      jgj 
with  the  mo-.t  patient  industry,  thai  even  those  more  or  less  qualified  to  undertake  the  task  have  held 
'hen  fore,  with  no  little  satisfaction  that  the  publishers  have  been  able  to  secure  this  very 
valuable  work  for  the    Ubaoribers   to  Wood's   Library  of  Standard   Medical  Authors.      Each  volume  is 
Complete  upon  the  topic,  of  which  it  treats.     Upon  completion,  subscribers  will  possess,  at  a  nominal 
cost,  the  fullest  and  mom  thorough  treatise  on  the  subject  of  modern  times. 

It  will  inter  to  know  that  the  cost  of  the  two  volumes  we  now  present,  is,  in  the 

original  English  edition,  over  §13.00. 

54 


a 


Catalogue  of  the  Titles  of  Works  published  in 

Wood's  Library  of  Standard  Medical  Authors. 


1  Tliird  Series.    Price,  $18.00.    Volumes  not  sold  separately. 

l        -,;MWW^M§:  H'  DICKINS0N'  M-D-     I11UStrated  Wkh  Plain  and  COl°red  ^hographic 
|  treSuponltin  the"  language8^  Standard  ^^  ^  intereStine  subJect>  and  is  the  ™st  complete 

|         MATERIA  MEDICA  AND  THERAPEUTICS  OF  THE  SKIN.     By  HENRY  G.  PIPFABD,  A  M., 

s^Z  r>'Jje;^or  ?J  Dermatology,  Medical  Department  of  the  University  of  ttie  City  of  Neio   York  ■ 

w  burgeon  to  Charity  Hospital,  etc.  ?*."!*!■• 

m  _    "  Morbi  epidermidem,  epithelium,  c?m'm,  et  cellnlosam  membranum  efficientes  tarn  multi  sunt  ut  vix 

«  L!L°f'-   neia  Patluntllr  redigi;  ex  medicamentis  autem  quae  maxime  ad  eorum  morborum  curationem 

/.  sunt  lm  usu,  hie  proponernus."— De  Goeter  (1740). 

£  83^=  This  original  work  is  probably  one  of   the  most  useful  books  for  the  general  practitioner 

g  ever  published  upon  the  subject,  containing  as  it  does  a  systematically  classified  mass  of  the  most  popu- 

•J  lar  and  recent  formulre. 

2  A  TREATISE  ON  DISEASES  OF  THE  JOINTS.     By  RICHARD  BARWELL,  P.R.C.S.     Surgeon 
m  Uia>ing- Cross  Hospital,  etc.     Illustrated  by  numerous  engravings  on  wood. 

-  j^r-  This  standard  book,  just  re-written  by  its  distinguished  author,  is,  by  special  arrangement  with 

-  mm,  published  in  this  library  in  advance  of  its  appearance  in  England. 

A  TREATISE  OH  THE  CONTINUED  FEVERS.  By  JAMES  C.  WILSON,  M.D.,  Attending  Phy- 
sician to  the  Philadelphia  Hospital  and  to  the  Hospital  of  the  Jefferson  Medical  College,  and  Lecturer 
JL,'USiV  D'?S>!1"S1S.  at  the  Jefferson  Medical  College,  Fellow  of  the  College  of  Physicians,  Phila- 
«»;  r/n  ri  m  ?  an  m,t,'°,duf^n  by  J-  M.  DA  COSTA,  M.D.,  Professor  of  the  Practice  of  Medicine 
',L  r?  ■  d'Cine,  atJhe  Jefferson  Medical  College,  Physician  to  the  Pennsylvania  Hospital.  Con- 
sulting Physician  to  the  Children's  Hospital,  Fellow  of  the  College  of  Physicians,  Philadelphia,  etc. 
f^P^!6  W°Uld  hardly  b?  P°SEib]e  t0  Present  to  the  profession  a  work  of  more  universal  interest  than 
tn  f'h  ille  ™  e  ls„sPecl.ally  Prepared  for  this  series,  and  necessarily  possesses  great  practical  value 
to  all  practitioners  of  medicine. 

A  MEDICAL  FORMULARY.  By  LAURENCE  JOHNSON,  A.M.,  M.D.,  Fellow  of  the  New  York 
Academy  of  Medicine,  etc. 

win^I  Jt'f  a  !?.nf?  time  since  the  first  publication  of  Ellis  and  of  Griffiths;  the  present  modern  work 
will,  therefore,  be  peculiarly  acceptable. 

THE/3?EiSES  OF  OLD  AGE.  By  J.  M.  CHARCOT,  M.D.,  Professor  in  Faculty  of  Medicine  of 
toJJiL  Tl!C'nr  ■  t]\e  ^alPetriere  ;  Member  of  the  Academy  of  Medicine  ;  of  the  Clinical  Society  of 
London  of  the  Clinical  Society  of  Buda-Pesth ;  of  the  Society  of  Natural  Sciences,  Brussels  ■  President 
of  the  Anatomical Society  etc.,  etc.  Translated  by  L.  HARRISON  HUNT.  M.D.,  with  numerous 
additions  by  A  L.  LOOMIS,  M.D.,  etc.,  Professor  of  Pathology  and  Practical  Medicine  in  the  Medical 
Department  of  the  University  of  the  City  of  New  York;  Consulting  Physician  in  the  Charity  Hospital  ■ 
to  the  Bureau  of  Out- Door  Relief;  to  the  Central  Dispensary;  Visiting  Physician  to  the  Bellevue 
Hospital;   to  the  Mount  Sinai  Hospital,  etc.,  etc. 

JS"  This  work  is  upon  a  subject  little  understood,  and  but  little  treated  of  by  authors      It  will  be 
almost  the  only  book  of  its  kind. 

COULSON   ON   THE    DISEASES   OF   THE    BLADDER  AND   PROSTRATE    GLAND       Sixth 
Edition.     Revised  by  WALTER  J.  COULSON,  F.R.C.S.,  Surgeon  to  St.  Peter's  Hospital  for  Stone  etc 
and  Surgeon  to  the  Lock  Hospital.     Illustrated  by  wood  engravings.  ' 

VW  This  standard  work  has  just  been  revised  and  is  most  highly  commended  by  the  leading  medical 
journals  of  England.  b 

GEuTrmuKE?^AunH?M/STEY;  ,A  practical  manual  for  the  »se  of  Physicians'.    By  R.  A. 
,    « ■      ?  A-^-'M-P'  Professor  of  Medical  Chemistry  and  Toxicology  in  the  University  of  Ver- 
mont, Member  of  the  Chemical  Societies  of  I'aris  and  Berlin,  New  York  Academy  of  Medicine,  etc. 

f^T  No  medical  chemistry  especially  intended  for  the  use  of  practising  physicians  has  appeared  for  a 
long  time ;  it  is  therefore  believed  this  "-will  fill  a  want  long  felt:' 

ARTIFICIAL    ANESTHESIA   AND   ANESTHETICS.      By  HENRY    M.   LYMAN,    AM     MD 
Professor  of  Physiology  and  Nervous  Diseases  in  Rush  Medical  College,  and  Professor  of  Theory  arid 
Practice  of  Medicine  m  the  Woman's  Medical  College,  Chicago,  III. 

EP~  The  first  comprehensive  and  complete  treatise  upon  this  comparatively  modern  and  verv  im- 
portant subject.  J 

A  TT? wAT.aS,Ev  °AF?0aD  AND  ^ETETICS.  Physiologically  and  Therapeutically  considered.  By 
i".  W.  l'AV  Y,  M.D.,  F.S.     Second  Edition. 

A  HANDBOOK  OF  UTERINE  THERAPEUTICS  AND  DISEASES  OF  WOMEN  Bv 
EDWARD  JOHN  TILT,  M.D.     Fourth  Edition.  wuivi^ju.      Ly 

DISEASES  OF  THE  EYE.  By  HENRY  D.  NO  YES,  M.D.,  Professor  of  Ophthalmology  and  Otology 
in  Bellevue  Hospital  Medical  College,  Surgeon  to  the  New  York  Eye  and  Ear  Infirmary,  etc  Illus- 
trated by  two  chromo-lithographs  and  numerous  wood  engravings. 

4.i.i^r-T,Ii?  treati8e  is  written  with  a  special  view  to  the  needs  of  the  general  practitioner,  and  treats 
the  subject  in  a  very  plain,  practical  way. 

55 


Catalogue  of  the  Titles  of  the  Works  published  iu 

Wood's  Library  of  Standard  Medical  Authors. 


Second  Series.     Price,  $1§.00.     Volumes  not  sold  separately.       © 


^ft 
ft 


*8 


VENEREAL  DISEASES.    By  E.  L.  KEYES,  A.M.,  M.D.,  Adjunct  Professor  of  Surgery,  and  Professor  s 

of  Dermatology  in  Jittlevue  Hospital  Medical  College ;  Consulting  Surgeon  to  the  Charity  Hospital ;  bt 

Surgeon  to  JJetlevue  Hospital,  etc.  S 

|3^~  Ii  makes  a  handsome  volume  of  361  pages,  thoroughly  covering  the  subject.     It  is  written  with  8 

special  reference  to  the  needs  of  the  physician  in  active  practice,  and  is.  well  illustrated.  *JJ 

A  HANDBOOK  OF  PHYSICAL  DIAGNOSIS:  Comprising  the  Throat,  Thorax,  and  Abdomen.     By  g 

DE.  PAUL  GUTTMAN,  Privut-Docent  in  Medicine,  University  of  Berlin.     Translated  from  the  Third  v 

German  Edition  by  ALEX.  NAPIER,  M.D.,  Fel.  Fac.  Physicians  and  Surgeons,  Gta.-goiv.     American  *■ 

Edition,  with  a  colored  plate  and  numerous  illustrations.  • 

JiW"  This  standard  work,  the  hiphest  authority  upon  the  subject,  has  passed  through  several  editions  J) 
in  Germany,  and  has  been  translated  into  French,  Italian,  Russian,  Spanish,  Polish,  and  English.     A 

volume  of  3 14  pages.  £ 

A  TREATISE  ON  FOREIGN  BODIES  IN  SURGICAL  PRACTICE.     By  ALFRED  POULET,  M.D.,  £ 

Adjutant  Surgeon- Major,  Inspector  of  the  School  for  Military  Medicine  at  Val-de-Grace.    Illustrated  „ 

by  original  wood  engravings.     Translated  from  the  French.     Volume  I.  m 

{S?F"  This  new  and  practical  work  upon  an  entirely  new  subject  is  of  unusual  interest  and  value.     It  ** 

is  translated  by  permission  of  ihe  author,  who  has  revised  and  corrected  it,  with  additions,  especially  j? 

for  this  series.     This  volume  is  illustrated  by  many  fine  engravings.  — 

A  TREATISE  ON  FOREIGN  BODIES  IN  SURGICAL  PRACTICE,     By  ALFRED  POULET,  M.D..  « 

Adjutant  Surgeon-Major,  Inspector  of  the. School  for  Military  Medicine  at  Val-dt-Orace.    Illustrated  _ 

by  original  wood  engravings.    Volume  II.  g 

A   TREATISE    ON    COMMON    FORMS   OF   FUNCTIONAL    NERVOUS    DISEASES.     By  L.  *-d 
PUTZEL,  M.D.,   Visiting  Physician  for  Nervous  Diseases,  Iiand.tlVs  Island  Hospital;  Physician  to 
the  Class  for  Nervous  Diseases,  Bellevue  Hospital  Out-Door  Department;  and  Pathologist  to  the  Lu- 
natic Asylum,  IS.  I. 

£3?~  This  volume  is  especially  prepared  for  use  of  general  practitioners,  and  treats  in  a  practical  way  ?  g 

of  the  forms  of  nervous  disorders  commonly  met  with  in  practice.     It  makes  a  book  of  262  pages.  w  * 

DISEASES    OF   THE    PHARYNX.  LARYNX  AND   TRACHEA.      By  MORRELL  MACKENZIE,  "  S 

M.  L>  ,  London.     Illustrated  by  112  fine  wood  engravings.  *© 

g3^"~  This  work,  by  the  best  English  authority  is  just  completed,  and  will  be  welcomed  by  the  profes- 
sion in  America.     It  makes  a  large  volume  of  440  pages.  S  _ 
THE    SURGERY.    SURGICAL    PATHOLOGY    AND    SURGICAL   ANATOMY   OF   THE    FE-  .2  « 
MALE  PELVIC  ORGANS  in  a  series  of  plates  taken  from  nature  with  commentaries,  notes,  and  £  i 
a    es  by  HENRY  SAVAGE,  M.D.,  London,  Fellow  of  the  lioyal  College  of  Surgeons  of  England,  one  S« 
of  the  Consulting  Medical  Oj/lcers  of  the  Samaritan  Hospital  for  Women.    Third  edition,  revised  and  ft» 
greatly  extended.  4>  0 
C^"32  full-page  lithographic  plates  and  22  wood  engravings,  with  special  illustrations  of  the  opera-  jj  fl 
lii  QBOn  Vesien- Vaginal  Fistula,  Ovariotomy,  and  Perineal  Operation.     This  is  the  cheapest  book  ever  _ 
published  on  any  branch  of  medicine  at  any  time,  and  is  almost  worth  the  entire  cost  of  the  twelve  ii 
volumes.  '2 
THERAPEUTICS.     Illustrated   by   D.    F.    LINCOLN,   M.D.,    from    the  Materia    Mcdica   and   Thera-  J 
peutic    ol     \.  TOS8EAU,  M.D.,  Professor  of  Therapeutics  of  the  Faculty   of  Medicine    of  Paris, 
Physician,   to    V Hotel    l)i(u.   etc.,   etc.,   1J.   P1DOUX.   M.D.,    Member  of   ihe.   Academy   of  Medicine,  «■ 
Purr,  etc.,  etc.,  and  CONSTANTTNE  PAUL,  M.D.,  Adjunct  Professor  of  the  Faculty  of  Paris,  Phy-  pfi 
m  to  the  St.  Antoiin  Hospital,  etc.    Ninth  French  Edition,  Revised  and  Edited.    Volume  I.    Any  ** 
work  by  Trossean  needs  no  introduction  to  the  Medical  Profession — his  profound  knowledge,  his  admir-  ^ 
able   facility   Of   imparting  instruction,  and  his  delightful  styie  commend  whatever  bears   his  name  to 
their  best  considi  ration.     This  work  is  said  to  be  superior  to  any  other  upon  the  subject,  and  one  which  * 
will   long  continue   to  be  a  standard.     The  editon  from  which  this  translation  is  made  has  been 
thoroughly  revised  and  edited  by  Dr.  Paul,  and  brought  down  to  Iho  present  year. 
THERAPEUTICS.     Translated  by  D.  I'.  LINCOLN,  M.D.,   from  the  Materia  Medica  and  Therapeutics  ft 
of                       !'.  M.  i>.,  Professor  of  Therapeutics  of  the  Faculty  of  Medicine  of  Parts,  Physicianto  v 
/  //                       .  etc.,  ii.  P]  DOUX,  M.D.,  M<  mb<  r  of  the  Academy  of  Medicine.  Pans,  etc.  etc,  and  ft 
mm;  PAUL,  .M.i  >..  Adjunct  Pi  ofei-sor  of the  Faculty  of  Paris,  Physician  to  the  St.  Antoine  £ 
//■  tpital,  etc.    Ninth  Edition,  Revised  and  Edited.    VolnmeH.  © 
THERAPEUTICS.     Translated  by  I).  !■'.  LINCOLN,  M.D.,  from  the  Materia  Medica  and  Therapeutics  of  " 
L  TROS8EAU,  M.  D.,  Professor  oj  Therapeutics  of  the.  Faculty  of  Medicine  of Pdris,  Physicianto  *> 
i  ii.r, i  lu.ii.  etc.,  etc.,   II.  PIDOl  '•■■  m  D.,  Member  of  the  Academy  af  Medicine,  Paris,  etc.,  etc..  and  7 
-TWi  IM.  PAUL,  M.I'..  Adjunct  Professor  of  the  Faculty  of  Paris,  Physician  to  the  St.  Antoine  $ 
Hospital,  etc     Ninth  French  Edition,  Revised  and  Edited.    VolumeJII.  & 
DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF  THE  EAR.— By  ALBERT  H.  BUCK,  M.P.,  H 
Instructor  m   Otology  in  the  College  of  Physicians  and  Surgeons,  New  York;  A ural  Surgeon  to  the  L 
x.    v    Eye  ami  Ear  I 'uji 'ruio r >/:  Editor  of  ZlemsserCs  Cyclopedia  of  the  Practice  of  Medicine,  and  Iffl 
\   i  eatlse  on  Hygiene  and  Public  Health.n 
MINOR  SURGICAL  GYNECOLOGY.      By  I'M   I.   P.    MUNDE,  M.D.     A  Manual  of  Uterine  Diagnosis 
and   thi                                                           rical   Practice,  for  the  Use  of  the  Advanced  student  und 
il  Practitioner,     in  one  octavo  volume  of  802  Pages,    With  800  illustrations. 

contain  many  hinis  concerning  the  minor  details  of  practice  in  the 
treatment  of  women,  oommonly  overlooked  In  general  treatises.    It  is  written  especially  for  this  library. 

56 


0 


Catalogue  of  the  Titles  of  Works  published  in 

Wood's  Library  of  Standard  Medical  Authors. 


First  Series.    Price,  $18.00.   Volumes  not  sold  separately. 


REST  AND  PAIN.  A  Course  of  Lectures  on  the  Influence  of  Mechanical  and  Physiological  Rest  in 
the  Treatment  of  Accidents  and  Surgical  Diseases  and  the  Diagnostic  Value  of  Pain.  By  JOHN 
HILTON,  F.R.S.,  F.R.C.S.     Edited  by  W.  H.  A.  JACOBSON,  P.R.C.S. 

DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.  Comprising  Articles  on— Enteralgia, 
by  JOHN  RICHARD  WARDELL,  M.D. ;  Enteritis,  Obstruction  of  the  Bowels,  Ulceration  of  the 
Bowels,  Cancerous  and  other  Growths  of  the  Intestines,  Diseases  of  the  Caecum  and  Appendix  Vermi- 
formis,  by  JOHN  SYER  BRISTOWE,  M.D. ;  Colic,  Colitis  and  Dysentery,  by  J.  WARBURTON 
BEG-BIE,  M.D.  ;  Diseases  of  the  Rectum  and  Anus,  by  THOMAS  BLIZZARD  CURLING,  F.R.S. ; 
Intestinal  Worms,  by  W.  H.  RANSOM,  M.D.  ;  Peritonitis,  by  JOHN  RICHARD  WARDELL,  M.D.  ; 
Tubercle  of  the  Peritoneum,  Carcinoma  ot  the  Peritoneum,  Affections  of  the  Abdominal  Lymphatic 
Glands  and  Ascites,  by  JOHN  SYER  BRISTOWE,  M.D. 

A  CLINICAL  TREATISE  ON  DISEASES  OF  THE  LIVER.  By  DR.  FRIED.  THEOD. 
FRERICHS.  Translated  by  CHARLES  MURCHISON,  M.D.  In  Three  Volumes,  Octavo.  Volume  I. 
Illustrated  by  a  full-page  Colored  Plate  and  numerous  fine  Wood  Engravings. 

A  CLINICAL  TREATISE  ON  DISEASES  OF  THE  LIVER.  By  DR.  FRIED.  THEOD. 
FRERICHS.  Translated  by  CHARLES  MURCHISON,  M.D.  In  Three  Volumes  Octavo.  Volume  II. 
Illustrated  by  a  full  pa?e  Plate  and  numerous  fine  Wood  Engravings. 

A  CLINICAL  TREATISE  ON  DISEASES  OF  THE  LIVER.  By  DR.  FRIED.  THEOD.  FRER- 
ICHS. Translated  by  CHARLES  MURCHISON,  M.D.  In  three  volumes,  octavo.  Volume  III. 
Illustrated  by  a  full-page  Plate  and  numerous  fine  Wood  Engravings. 

MATERIA  MEDICA  AND  THERAPEUTICS.  (Vegetable  Kingdom.)  By  CHARLES  D.  F. 
PHILLIPS,  M.D. ,  F.R.C.S. E.,  Lecturer  on  Materia  Medico,  at  Westminster  Hospital,  London.  Re- 
vised and  adapted  to  the  U.  S.  Pharmacopoeia  by  HENRY  G.  PIFFARD,  A.M.,  M.D.,  Professor  of  Der- 
matology, University  of  the  City  of  New  York,  Surgeon  to  the  Charity  Hospital,  etc.,  etc.  This  prac- 
tical book  forms  a  volume  in  this  series  of  327  pages. 

A  CLINICAL  TREATISE  ON  THE  DISEASES  OF  THE  NERVOUS  SYSTEM.  By  M.  ROSEN- 
THAL, Professor  of  Diseases  of  the  Nervous  System  at  Vienna.  With  a  preface  by  Professor 
CHARCOT.  Translated  from  the  Author's  revised  and  enlarged  edition  by  L.  PUTZEL,  M.D.,  Piiys- 
icijintoihe  Class  for  Nervous  Diseases,  Bellevue  Out-door  Dept.,  and  Pathologist  to  the  Lunatic 
Asylum,  BlackweWs  Island.  In  two  volumes.  Volume  I.  Illustrated  with  fine  Woodcuts.  This  new 
edition  of  Prof.  Rosenthal's  work  is  pronounced  by  the  most  eminent  neurologists  to  be  the  best  treatise 
extant  upon  the  subject,  clear  in  its  pathology  and  full  and  practical  in  therapeutics.  This  is  a  volume 
of  SSI  pages. 

A  CLINICAL  TREATISE  ON  THE  DISEASES  OF  THE  NERVOUS  SYSTEM.  By  M.  ROSEN 
THAL,  Professor  of  Diseases  of  the  Nervous  System  at  Vienna.  With  a  Preface  by  Prof.  CHARCOT. 
Translated  from  the  Author's  revised  and  enlarged  edition  by  L.  PUTZEL,  M.D.     Volume  II. 

DISEASES  OF  WOMEN.  By  LAWSON  TAIT,  F.R.C.S.  A  new  Edition,  with  considerable 
additions,  prepared  by  the  Author  expressly -for  this  Library.  This  very  compact,  useful  book  makes  a 
volume  of  204  pages,  with  illustrations. 

INFANT  FEEDING,  AND  ITS  INFLUENCE  ON  LIFE  ;  Or,  The  Causes  and  Prevention  of 
Infant  Mortality.  By  0.  H.  F.  ROUTH,  M.D.  Third  Edition.  This  unique  work  forms  a  volume  of 
280  pages  in  this  Library. 

A  PRACTICAL  MANUAL  OF  THE  DISEASES  OF  CHILDREN,  WITH  A  FORMULARY. 
By  EDWARD  ELLIS,  M.  D.  Third  Edition.  This  standard  book  makes  a  volume  in  this  series  of 
225  pages. 

A  MANUAL  OF  SURGERY.  By  W.  FAIRLIE  CLARKE,  M.A.and  M.B.  (Oxon.),  F.R.C.S.,  Assistant 
Surgeon  to  Charing  Cross  Hospital.  A  new  Edition,  thoroughly  revised,  with  important  additions  by 
an  American  surgeon.     Nearly  200  illustrations.     Over  300  pages. 

57 


NEARLY    ONE    HUNDRED 

DISTINGUISHED    AUTHORS, 


HAVE    CONTRIBUTED    TO 

WOODS'    LIBRARY 

OF 

Standard  Medical  Authors, 

INCLUDING 

Profs.    A.    L.    LOOMIS— J.    M.  DA  COSTA— HENRY  D.  NOYES— E.    L.    KEYES— A.    H.  BUCK- 
P.  F.  MUNDE— H.  G.  PLFFARD— R.  A.  WTTTHAUS— H.  M.  LYMAN— M.   ROSENTHAL— 
F.  T.  FRERICHS— W.  ERB— E.  L.  PARTRIDGE— A.   TROUSSEAU— J.  M.    CHAR- 
COT—E.    ZTEGLER— E.    A.    PARKES— W.  GRIESLNGER— G.    V.    ELLIS, 

AND 

Drs.    L.   JOHNSON— PROSSER  JAMES— J.   C.    WILSON— R.    BARWELL— G.   M.    STERNBERG- 
MORRELL    MACKENZIE—  L.    S.    PLLCHER— C.    M.    TIDY— L.    PUTZEL— H.    SAVAGE— 
W.   B.   CARPENTER— BENJ.  HART— C.   PAUL— C.   B.   KELSEY— C.  D.  F.  PHIL- 
UPS— J.   HILTON— W.    T.  BELFIELD— W.  J.  COULSON— L.  TAIT— F.  W. 
PAVY— P.    GUTTMANN— W.    F.    CLARKE— ETC.,   ETC.,    ETC. 


THERE     HAS     BEEN     INCLUDED     IN     THE     LIBEAEY,    IN     THE     FIRST     SIX     SERIES, 

THIRTY-FOUR 

Beautifully    Colored    Full-page    Lithographic    Plates, 

ONE     HUNDRED     AND     SEVENTY 
BLACK    AND    TINTED 

FULL-PAGE     LITHOGRAPHIC      PLATES, 

IN  ALL 

OVER    TWO    HUNDRED    PLATES, 

CONTAINING    SEVERAL  HUNDRED    FIGURES, 

AND   NEARLY 

FIVE      THOUSAND 

OF    THE    FINEST,    AND    MOSTLY    ORIGINAL,    WOOD    ENGRAVINGS, 

ALL    OF   WHICH   HAS   BEEN    SUPPLIED    AT    THE   MERELY 
NOMINAL   COST  OF 

FIFTEEN     DOLLARS    A    YEAR 

TO  THE  REGULAR  SUBSCRIBER. 

58 


NOW  COMPLETE. 

Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine, 

In  Twenty  Royal  8vo  Vols.,  including  Buck's  Hygiene  (2  vols.),  and  the  General  Index. 
WITH  WHICH  SET  IS  PRESENTED  A  COPY  OE 

ZIEMSSEN'S  HANDBOOK  OF  DISEASES  OF  THE  SKIN. 


This  great  work,  the  most  full  and  complete  treatise  upon  the  practice  of 
medicine  in  any  language,  is  now  complete.  It  is  a  standard  which  will  long 
maintain  its  place  as  the  great  storehouse  of  medical  knowledge. 

It  seems  proper  upon  the  conclusion  of  this  great  work  to  ask  attention  to  a 
few  facts  in  connection  with  its  translation  and  reprint.  The  attention  of  Wm. 
Wood  &  Co.  was  first  directed  to  the  advertisement  of  the  German  publisher,  in 
the  early  part  of  1873.  After  consultation  with  a  number  of  prominent  gentle- 
men of  the  profession,  they  concluded  to  venture  upon  the  translation  and  pub- 
lication in  English  of  the  work  to  which  it  referred,  the  largest  undertaking,  by 
far,  both  as  to  the  editorial  labor  and  the  amount  cf  money  involved,  of  any 
medical  publication  in  the  English  language. 

The  estimates  of  the  cost  of  the  volumes,  and  the  price  at  which  the  publish- 
ers could  sell  them,  were  based  wholly  upon  the  published  plans  of  Mr.  Vogel — 
thus,  while  the  :'  copy  "  came  from  Germany  with  most  satisfactory  regularity, 
it  was  soon  found  that  the  volumes  would  much  exceed  the  estimated  number 
of  pages ;  and,  after  several  years  of  publishing  largely  increased  volumes,  it  was 
found  that,  even  with  such  addition,  it  would  be  impossible  to  complete  the  work 
iu  the  fifteen  volumes,  as  at  first  announced.  The  alternative  then  presented 
was,  to  increase  the  number  of  volumes,  or  abridge  the  matter  ;  the  latter  course 
would  have  been  much  preferred  by  the  publishers,  as  enabling  them  to  adhere 
strictly  to  their  original  estimates.  So  many  influential  subscribers  objected,  how- 
ever, that  the}'  felt  compelled  to  announce  that  two  volumes  would  be  added  to 
the  set.  It  was  hardly  to  be  expected  that  there  would  be  absolutely  no  adverse 
criticism  of  this  course  among  so  large  a  constituency  as  the  subscribers  to  this 
work.  It  has  been  very  gratifying,  however,  to  find  that  this  change,  wholly  be- 
yond their  control,  has  been  unsatisfactory  to  less  than  one  per  cent,  of  the  sub- 
scribers. To  show  the  difference  between  what  they  promised  and  what  has  ac- 
tually been  given  subscribers  to  Ziemssen's  Cyclopaedia,  the  publishers  give 
herewith  the  number  of  pages  of  each  volume,  in  comparison  with  the  average 
number  as  at  first  estimated,  viz.  : 

Promised,  per  volume,  500  to  700  pages.         Average  of  600. 

jes.       Vol.  7  =  1,060  pages.       Vol.  13=    987  pages, 
"     8=    949     "  "     14=    911      " 

«     9=    936     "  "     15=    808      " 

"  10=    584     "  "     16  =  1,071       " 

"  11=    636     "  "     17=    982      " 

"  12=    914     "  

Total  number  of  pages  already  received  by  Subscriber,       -''•--''..--     14,596 
"  "  "      as  promised  .by  Publishers,        ------     10,200 

Given  to  Subscribers  above  their  expectations,  -  -  -  4,396  pages, 
or  the  equivalent  of  7-1  volumes  of  from  600  to  700  pages  each.  To  the  above  is 
now  to  be  added  still  another  extra  volume — Diseases  of  the  Skin. 

It  is,  of  course,  well  known  that  though  this  extra  matter  has  cost  the  sub- 
scribers nothing,  it  entailed  a  very  heavy  and  unlooked-for  expense  upon  the 
publishers.  They  believe,  however,  this  endeavor  to  do  justly  and  generously  by 
those  who  had  supported  this  great  undertaking  has  been  appreciated  by  them. 

It  is  with  no  little  satisfaction  that  the  publishers  can  look  back  to  the  unex- 
ampled regularity,  in  book-publishing,  Avith  which  the  volumes  appeared  every 
three  months  for  over  three  years,  and  it  is  with  great  pleasure  that  the  publish- 
ers can  now  congratulate  the  subscribers  and  themselves  upon  the  completion  of 
the  work.  WM.  WOOD  &  CO.,  Publishers. 

59 


Given, 


Vol. 

1=  724  pa 

t'e 

2=  763  ' 

a 

3=  684  " 

a 

4=  824  ' 

a 

5=  726  ' 

ce 

6=1,038  " 

ZIEMSSEN'S    CYCLOPEDIA 

OF   THE 

PRACTICE  OF  MEDICINE. 

This  great  work,  the  most  full  and  complete  treatise  upon  the  practice  of  medicine  in  any  language,  is 
now  completed.  It  is  a  standard  which  will  long  maintain  its  place  as  the  great  storehouse  of  medical 
knowledge. 

In  now  closing  the  record  of  the  publication  of  this  great  work,  the  Publishers  desire  again  to  call 
attention  to  the  great  difference  in  the  amount  of  matter  promised  by  them  to  the  subscribers  and  the 
amount  that  has  actually  been  given  to  them. 

Promised,  per  volume,  500  to  700.  Average  of  600. 

f  Volume  1=    724  pages.  Volume  7=1.060  pages.  Volume  13=    987  pages. 

2=    763      "  '•        8=    949      "  "        14=    911     " 

/-;„,»„]         "        3=    6S4      "  ';        9=    936      "  "        15=    808     " 

OC%A  It  it  if>„        COO  (f  It  lf)=1     071  il 

17=  '982     " 

14      '•  "  

Total  number  of  pages  already  received  by  Subscriber,  ------        14,696 

"  li        "       '•      as  promised  by  Publishers,    .-------    10,200 


2=  763 

1 

3=  6S4 

1 

4=  824 

1 

5=  726 

I 

6  =  1,028 

8= 

949 

9= 

936 

10  = 

5S3 

11  = 

636 

12= 

914 

G-iven  to  Subscriber.*  above  their  expectations,  -  -  4.406  pages, 
or  the  equivalent  ofi}i  volumes  of  from  600  to  700  pages  each.  To  the  above  is  now  to  be  added  still 
another  extra  volume — viz.:  Diseases  of  the  Skin. 

COITTEUTS. 

1. — Acute  Infectious  Diseases.     Tart  1.  j   Vol.12. — Diseases  of  the  Brain  and  its  Membranes. 

13. — Disea=es  of  the  Spinal  Cord  and  Medulla 
Oblongata. 

14. — Disea-es  of  the  Nervous  System  and  Dis- 
turbances of  Speech. 

15. — Diseases  of  the  Kidnt-y. 

16. — Liseases  of  the  Locomotive  Apparatus  and 
General  Anomalies  of  Nutrition. 

17. — General  Anomalies  of  Nutrition  and  Poison. 

18. — Hysiene  and  Public  Health.     Part  1. 

I0-.— Hygiene  and  Public  Health.     Part  2. 


"    2. — Acute  Infectious  Diseases.     Part  2. 

"    3. — Chronic  Infectious  Diseases. 

"    4. — Disea  -es  of  the  Respiratory  Organs.  Parti. 

"    5. — Diseases  of  the  Respiratory  Organs.    Part  2. 

"    6. — Diseases  of  the  Circulatory  Organs. 

"     7. — Diseases  of  the  Chylopoetic  System.   Parti. 

"    8. — Diseases  of  the  Chylopoetic  System.  Part  2. 

"    9. — Diseases  of  the  Liver  and  Portal  Vein. 

"  10.  —  Diseases  of  the  Female  Sexual  Organs. 

"  11. — Diseases  of  the  Peripheral  Cerebro-Spinal 

Nerves.  "   20. — General  Index  to  the  Whole  Cyclopaedia. 

ZIEMSSEN'S   HANDBOOK  OF  THE   DISEASES  OF  THE  SKIN. 
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fur  the  entire  work  i-s  a  neces&i  ..  ;  in  fact,  it  is  alm<>-i  impossible  to  avail  one's  self  of  the  treasures  of 
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SURGERY 


CONTENTS    OR    THE    VOLUMES. 

VOIi.   I     GENERAL  SURGERy,    OPERATIVE,  MINOR,  AND  PLASTIC  SURGERY.    AMPUTATIONS. 
POX.    //.     I  N.J  l   |;l  I :-    \  •■:  I »  DISEASES  WHICH  MAY  OCCUR  IX  ANY   PART  OF  THE  BODY.     YEXERJ 

DISEASES.     INJURIES  AND  DISEASES  OF  VARIOUS  TISSUES  OF  THE  BODY. 
I  <>!..    III.     INJURIES  AND  DISEASES  OF  THE  NERVES,  BLOOD-VESSELS,  AXD  BONES. 
VOL.   rF.— INJURIES  AND  DISI'.ASKS  OF  THE  JOINTS.    EXCISIONS  AXD  RESECTIONS.    TREATS 

OF  DEFORMITIES.     [NJURIES  AXD  DISEASES  OF  VARIOUS  REGIONS  OF  THE  BODl 
<<>/..    /.     REGIONAL  SURGERY  CONTINUED. 
VOL.     II.     REGIONAL    BURGERY    CONCLUDED.      HISTORY   OF   SURGERY.     APPENDIX.     CEXE 

I  v  I  > ) :  ■:  TO  THE  WHOLE  SIX  VOLUMES. 

VOLUMES  I.,  II,   III.,  IV.,  V,  N<»\V  UIOADV;    V(H,UMli  VI.,  IN  DECEMBER-. 

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62 


INDEX. 


PAGE 

ALLEN,  P.     Lectures  on  Aural  Catarrh 32 

ANATOMICAL  REMEMBRANCER 1 

ASHB Y,  H.     Memoranda  of  Physiology 17 

ASHHURST,  J.  The  International  Encyclo- 
paedia of  Surgery 25 

BARTHOLOW,  R.     Spermatorrhoea 38 

BARWELL,  R.     A  Treatise  on  Diseases  of  the 

Joints 4 

BAUER,  L.     Lectures  on  Orthopaedic  Surgery..  23 
BEARD,  G-.  M.     Nervous  Exhaustion,  Neuras- 
thenia    35 

BEDFORD,  G.  S.     The  Principles  and  Practice 

of  Obstetrics 26 

Clinical  Lectures  on  tile  Diseases  of  Women 

and  Children.  '..'A 26 

BELFIELD,  W.   T.     Diseases  of.  the  Urinary 

and  Hale  Sexual  Organs 38 

BELL,  A.  N.     Climatology 17 

BENEDIKT,    M.      Anatomical    Studies    upon 

Brains  of  Criminals 37 

BENNETT,  J.  H.     Clinical    Lectures    on    the 

Principles  and  Practice  of  Medicine.  . .     8 

BIGELOW,  J.     Nature  in  Disease 9 

Brief  Exposition  of  Rational  Medicine 9 

BINZ,  G.     The  Elements  of  Therapeutics 15 

BLYTH,  A.  W.     The  Analysis  of  Food  and  the 

Detection  of  Poisons 22 

BOCK,  C.  E.     Atlas  of  Human  Anatomy  with 

Explanatory  Text 22 

BODENHAMER,  W.    Practical  Observations 

on  Anal  Fissure 13 

Congenital  Malformations  of  the  Rectum 

and  Anus    13 

An  Essay  on  Rectal  Medication 13 

On  the  Hemorrhoidal  Disease 13 

The  Physical  Exploration  of  the  Rectum. .   13 

BOSWORTH.  F.  H.     Diseases   of  the   Throat 

and  Nose 33 

BRAMWELL,  B.     The  Diseases  of  the  Spinal 

Cord 36 

BR AUN,  G.  R.     Unemic  Convulsions 27 

BRISTOWE,  WARDELL,  and  OTHERS. 
Diseases  of  the  Intestines  and  Perito- 
neum ...    8 

BROCKLESBY  J.     The  Amateur  Microscopist.  21 

BRODIE,  B.     Mind  and  Matter IS 

BROWN,  H.  E.  Report  on  Quarantine  on  the 
Southern  and  Gulf  Coasts  of  the  United 

States 15 

BROWN,  W.  S.     A  Clinical  Handbook   on  the 

Diseases  of  Women 2S 

BUCK,  A.  H.  A  Treatise  on  Hygiene  and  Pub- 
lic Health 46 

• Diagnosis  and  Treatment  of  Ear  Diseases.  32 

BURRALL,  F.  A.     Asiatic  Cholera 15 

BUSEY,  S.  C.  Congenital  Occlusion  and  Dila- 
tion of  Lymph  Channels 41 

BYFORD,  W.  H.     A  Treatise  on  the  Theory  and 

Practice  of  Obstetrics 27 

CARNOCHAN,  J.  M.     Congenital  Dislocations 

of  the  Head  of,  Femur 23 

CARPENTER,  W.  B.     The  Microscope  and  Its 

Revelations 21 

CARPENTER,  W.  M.     An  Index  of  Medicine.  10 
CASTLE,  F.  A.     Wood's  Household  Practice  of 

Medicine 10 

CAZENAVE     and    SCHEDEL.      Manual     of 

Diseases  of  the  Skin 41 

CHAPMAN,  E.  N.    Hysterology 27 

CHARCOT,  J.  M.     Clinical    Lectures    on    the 

Diseases  of  Old  Age 5 

Lecture  on  Bright' s  Disease 40 

Lectures  on  Localization  in  Diseases  of  the 

Rrain   37 

CLARK,  W.  F.     A  Manual   of  the  Practice  of 

Surgery   23 

CODE  OF  MEDICAL  ETHICS 9 


PAGE 

COMSTOCK    and   COMINGS.     Principles  of 

Physiology 17 

CORSON,  J."  W.  On  the  Treatment  of  Pleurisy.  12 
COULSON,  W.  J.  Bladder  and  Prostate  Gland.  38 
CQRTIS,    E.      Manual    of    General    Medicinal 

Technology 9 

DELAFIELD,  F.     Studies  in  Pathological  An- 
atomy, Vol.  I.  and  II 3 

DELAFIELD  and  PRUDDEN.     Pathological 

Anatomy  and  Histoloay 3 

DELAFIELD    and    STILLMaN.     A  Manual 

of  Physical  Diagnosis 15 

DE  WECKER",  L.     Ocular  Therapeutics 32 

DICKINSON,  W.  H.     On   Renal  and   Urinary 

Affections 40 

DIDAY,  P.    A  Treatise  on  Syphilis  in  New-born 

Children , 41 

DRAPER,  J.  C.     Laboratory  Course  in  Medicai 

Chemistry 45 

DUNCAN,  J.  M.     Perimetritis  and  Parametritis  25 

:  On  the  Mortality  of  Child-bed  and  Mater- 

\  nity  Hospitals 25 

D  WIGHT,  T.     Frozen  Sections  of  a  Child 30 

EDES,    R.   T.     Therapeutic    Handbook   of  the 

United  States  Pharmacopoeia 43 

ELLIS  and  FORD.  lustrations  of  Dissections  2 
ELLIS,  E.    Diseases  of  Children,  with  Formulary  29 

EMMET,  T.  A.     Vesico-Vaginal  Fistula 28 

ERB,  W.     Electro-Therapeutics 6 

ERICHSEN,  J.  E.  On  Concussion  of  the  Spine  36 
FLINT,     A.     Compendium  of    Percussion  and 

Auscultation 10 

FOOTE,  J.     Ophthalmic  Memoranda 30 

Pharmacopoeia  and  Universal  Formulary  .  43 

FOTHERGILL,  J.  M.     The  Physiological  Fac- 
tor in  Diagnosis  17 

Indigestion,  Biliousness,  and  Gout 14 

FOWLER,  E.  P.     Suppression  of  Urine 39 

FOX,  T.     Skin  Diseases 42 

FRERICHS,  F.  T.  Diseases  of  the  Liver  ....  S 
FREY,  H.      The  Microscope  and  Microscopical 

Technology 21 

FRITSCH,  H.     Diseases  of  Women 28 

GARRIGUES,  H.  J.  Diagnosis  of  Ovarian  Cysts  26 
GARROD,  A.  B.     Essentials  of  Materia  Medica 

and  Therapeutics 14 

GODDARD,   P.  B.     The  Anatomy,  Physiology, 

and  Pathology  of  Human  Teeth 24 

GOULEY.    J.   W.   S.     Diseases  of  the  Urinary 

Organs  39 

GOWERS,  W.  R.     Epilepsy,  etc 36 

■  Diagnosis  of  Brain  Disease 36 

GRAHAM.  D.  A  Practical  Treatise  on  Massage  6 
GREGORY,  G.  Lectures  on  the  Eruptive  Fevers  7 
GRIE  SINGER,    W.      Mental     Pathology     and 

Therapeutics 20 

GUTTMAN,  P.    A  Handbook  of  Physical  Diag- 
nosis  16 

HAMILTON,  A.  McL.     Types  of  Insanity....  37 
HAMILTON,  F.  H.     The  Principles  and  Prac- 
tice of  Surgery 22 

HARRIS  and  POWER.    Manual  of  the  Physio- 
logical Laboratory 19 

HARRISON,  R.     The  Surgical  Disorders  of  the 

Urinary  Organs 38 

HART  ard  BARBOUR.  Manual  of  Gynecology  28 
HELMHOLTZ,   H.     The   Ossicles  of  the  Ear 

and  Membrana  Tympani ....  32 

HENOCH,  E.     Lectureson  Diseases  of  Children  30 

HILTON.  J.     On  Rest  and  Pain 3 

HOLDEN  and  SHUTER  Human  Osteology  .  2 
HOLMES.  T.     A  System  of  Surgery  by  Various 

Writers 23 

HOOPER'S      PHYSICIAN'S     VADE     ME- 
CUM.     A  Manual  of  the  Principles  and 

Practice  of  Physic 9 

HOSPITAL  PLANS 46 


G4 


PUBLICATIONS  OF  WILLIAM  ^YOOD  &  COMPANY. 


Index. 


PAGE 

HUN,  H.  A  Guide  to  American  Medical  Stu- 
dents in  Europe 46 

INGALS,  E.  F.  Diagnosis  and  Treatment  of 
Diseases    of    the    Chest,    Throat,    and 

Nasal  Cavifes 12 

JACOBI.  A.     A  Treatise  on  Diphtheria 34 

JAMES,  P.     Laryngoscopy  and  Rhinoscopy 34 

JOHNSON,  L.     A  Medical  Formulary 43 

A  Medical  Botany IT 

JOHNSON  and  MARTIN.  The  Influence  of 
Tropical  Climates  on  European  Consti- 
tutions    46 

KEETLEY,  C.  B.     An  Index  of  Surgery 22 

KELSEY,  C.  B.     Diseases  of  the  Rectum  and 

Anus 12 

KEYES.  E.  L.     Venereal  Diseases 41 

KIRBY,  F.  O.  A  Treatise  on  Veterinary  Medicine  40 
KIRKE'S  HANDBOOK  OF   PHYSIOLOGY.  IS 
KLOB,  J.  M.     Pathological  Anatomy  of  the  Fe- 
male Sexual  Organs 27 

KNAFF,  H.     On  Intraocular  Tumors 31 

LAMBERT,  T.  S.     Primary  Systematic  Human 

Physiology,  Anatomy,  and  Hygiene IS 

LEWIN,  L. "  The  Incidental  Effects  of  Drugs. . .  45 

LID  E  LL.  J.  A.     Apoplexy 36 

LIVEING,  R.     On  Treatment  of  Skin  Diseases.  41 

Diagnosis  of  Skin  Diseases 41 

LONGSTRETH,    M.     Rheumatism,  Gout,  and 

some  of  the  Allied  Diseases 4 

LOOMIS,  A.  L.     Lectures  on  Fevers 11 

On   Diseases  of   the   Respiratory   Organs, 

Heart,  and  Kidneys ....    11 

A  Text-book  of  Practical  Medicine 11 

Lesson  in  Physical  Diagnosis 16 

LYMAN,   H.    M.  "    Artificial  Anaesthesia  and 

a  nsestbetics 4 

MACKENZIE,    M.     Diseases  of  the  Pharynx, 

Larynx,  and  Trachea 34 

MILTON,  J."  L.     Pathology  and   Treatment  of 

Gonorrhoea 38 

MILLARD,  H.  B.     On  Bright's  Disease  of  the 

Kidneys 39 

MORGAN,  C.  E.  Electro-Physiology  and  Thera- 
peutics.     6 

MUNDE,  P.  F.     Minor  Surgical  Gynecology  ...  25 
MURCHISON,  C.    On  Functional  Derangements 

of  the  Liver S 

NEUBAUER  AND  VOGEL.     A  Guide  to  the 

Qualitative   and   Quantitative  Analysis 

of  the  Urine     38 

NOYES.  H.  D.    On  the  Diseases  of  the  Eye 30 

OLDBERG,  O.  and  WALL,  O.  A.    A  Companion 

to  the  United  States  Pharmacopoeia...   44 

OWEN.  R.    The  Skeleton  and  the  Teeth 25 

PARKES,  E.     A  .Manual  of  Practical  Hygiene  ..  46 
PARTRIDGE,  E.  L.    A  Manual  of  Obstetrics  . .   SB 

PAUL,  C.     Diseases  of  the  Heart 10 

PAVY,  F.  W.    On  Food  and  Dietetics 22 

PEABODY,   G.   L.     Supplement    to  Ziemssen's 

oredia 10 

PHARMACOPOEIA     OF     THE       UNITED 

STATES IS 

PHILLIPS,  C.  D.  F.  Materia  Medica  and  Thera- 

e  Kingdom)  11 

Materia   Medica  and   Therapeutics  (Inor- 

'-■'"  ...  14 

PICTURES  FOR  PHYSICIANS'  OFFICES 

AND  LIBRARIES 46 

PIFFARD,  H.  G.     A  Guide  to  Urinary  Analysis  40 

'in  the  Materia  Medica  and  Therapeutics 

of  the  Skin     -10 

PILCHER,  L.  S.    The  Treatment  of  Wounds...  y.| 
POULET,  A.    On    Foreign   Bodies  in   Surgical 

Practice 24 

PRESCRIBER'S    MEMORANDA  20 

PUTZEL,  L.    mi  Common  Forms  of  Functional 

hoi  .  86 

QUAIN'S  Elemeni    ol   Anatomy  1 

RANNEY,  A.  L.     Practical  Medical  Anatomy  ..     2 

A  Practical  Treatise  on  Surgical  Diagno 

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